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Review
. 2021 Nov 19;10(22):5419.
doi: 10.3390/jcm10225419.

Practice Guidelines of the Central European Hepatologic Collaboration (CEHC) on the Use of Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease Undergoing Invasive Procedures

Robert Flisiak  1 , Krasimir Antonov  2 , Pavel Drastich  3 , Peter Jarcuska  4 , Marina Maevskaya  5 , Mihály Makara  6 , Željko Puljiz  7 , Borut Štabuc  8 , Anca Trifan  9
Affiliations
Review

Practice Guidelines of the Central European Hepatologic Collaboration (CEHC) on the Use of Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease Undergoing Invasive Procedures

Robert Flisiak et al. J Clin Med. .

Abstract

Background: Second-generation thrombopoietin receptor agonists (TPO-RAs) are emerging as the new standard for managing thrombocytopenia (TCP) in patients with chronic liver diseases (CLDs) undergoing scheduled procedures. However, practical guidance for their routine use in CLD patients undergoing specific invasive procedures is lacking.

Methods: These practice guidelines were developed by the Initiative Group for Central European Hepatologic Collaboration (CEHC), composed of nine hepatologist/gastroenterologist experts from Central Europe. Using an adapted Delphi process, the CEHC group selected ten invasive procedures most relevant to the hepatology/gastroenterology setting in the region. Consensus recommendations for each invasive procedure are reported as a final percentage of expert panel responses.

Results: A consensus was agreed that TPO-RAs should be considered for raising platelet count in CLD patients undergoing scheduled abdominal surgery, high-bleeding risk dentistry, endoscopic polypectomy, endoscopic variceal ligation, liver biopsy, liver surgery, liver transplantation and percutaneous ablation, but it was also agreed that they are less beneficial or not necessary for endoscopy without intervention and paracentesis.

Conclusions: Using a modified Delphi method, experts reached an agreement for TCP management in CLD patients undergoing ten invasive procedures. These practice guidelines may help with decision making and patient management in areas where clinical evidence is absent or limited.

Keywords: avatrombopag; chronic liver disease; platelet transfusion; surgical procedures; thrombocytopenia; thrombopoietin receptor agonists.

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Conflict of interest statement

All authors declare no conflict of interest. The sponsor had no role in the collection, analyses, or interpretation of data in the writing of the manuscript or in the decision to publish the results.

Figures

Figure 1
Figure 1
Pooled responders not requiring a platelet transfusion prior to an invasive procedure in ADAPT-1 and ADAPT-2 (avatrombopag) and L-PLUS 1 and L-PLUS 2 (lusutrombopag). Responders are defined as the subjects who achieved platelet count ≥ 50 × 109/L on the day of the procedure. ADAPT-1/ADAPT-2 [18,19] and L-PLUS 1 [21]/L-PLUS 2 [22] are phase 3 trials for avatrombopag and lusutrombopag, respectively.
Figure 2
Figure 2
Consensus treatment algorithm for the use of TPO-RAs and platelet count threshold in CLD patients with TCP scheduled to undergo an invasive procedure. Contraindications for TPO-RA treatment include patients with a history of thrombotic events, portal vein thrombosis, and COVID-19 infection. Color code: green = procedure can be performed, yellow = procedure may be considered and red = procedure is generally not recommended. CLD, chronic liver disease; COVID-19, coronavirus disease 2019; TCP, thrombocytopenia.
See this image and copyright information in PMC

References

    1. Marcellin P., Kutala B.K. Liver diseases: A major, neglected global public health problem requiring urgent actions and large-scale screening. Liver Int. 2018;38((Suppl. 1)):2–6. doi: 10.1111/liv.13682. - DOI - PubMed
    1. Brown C.L., Hammill B.G., Qualsls L.G., Curtis L.H., Muir A.J. Significant morbidity and mortality among hospitalized end-stage liver disease patients in Medicare. J. Pain Symptom Manag. 2016;52:412–419.e1. doi: 10.1016/j.jpainsymman.2016.03.013. - DOI - PMC - PubMed
    1. Cortesi P.A., Conti S., Scalone L., Jaffe A., Ciaccio A., Okoslicsanyi S., Rota M., Fabris L., Colledan M., Fagiuoli S., et al. Health related quality of life in chronic liver diseases. Liver Int. 2020;40:2630–2642. doi: 10.1111/liv.14647. - DOI - PubMed
    1. Mitchell O., Feldman D.M., Diakow M., Sigal S.H. The pathophysiology of thrombocytopenia in chronic liver disease. Hepat. Med. 2016;8:39–50. doi: 10.2147/HMER.S74612. - DOI - PMC - PubMed
    1. Scharf R.E. Thrombocytopenia and hemostatic changes in acute and chronic liver disease: Pathophysiology, clinical and laboratory features, and management. J. Clin. Med. 2021;10:1530. doi: 10.3390/jcm10071530. - DOI - PMC - PubMed

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