Low platelets (thrombocytopenia) – a guide for people with lymphoma

Freephone helpline 0808 808 5555
[email protected]
www.lymphomas.org.uk
Low platelets (thrombocytopenia) –
a guide for people with lymphoma
Platelets are part of your blood. They help to form a blood clot and stop you bleeding
if you cut yourself. Some people with lymphoma may have times when they have
fewer platelets than they should. This means they will be more at risk of bleeding.
The medical name for having low platelets is ‘thrombocytopenia’, as platelets are also
called ‘thrombocytes’.
This leaflet aims to answer the questions that people with lymphoma might ask about
having low platelets:
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What are platelets and what do they do? (see below)
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What causes low platelets in people with lymphoma? (page 2)
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What will happen to me if I have low platelets? (page 3)
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What should I do if I start bleeding? (page 4)
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How are low platelets treated in people who have lymphoma? (page 4)
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How can I reduce my risk of bleeding? (page 5)
What are platelets and what do they do?
The blood contains three main types of blood cells:
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red cells, which carry oxygen
A red cell, white cell and platelet (left to right)
around the body
white cells, which fight infection
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platelets, which stick together
when your blood needs to clot.
These blood cells are all made in the
bone marrow, the spongy, jelly-like
material in the middle of our large bones. Platelets are produced by huge cells in the bone marrow called ‘megakaryocytes’. Usually platelets last about 10 days in our bloodstream
bbefore they are removed by the spleen. The bone marrow is constantly (Science Photo Library / P242/0105)
working to produce new platelets. It
will work harder if platelets are being used to stop bleeding somewhere in the body.
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Platelets are needed for the first stage of blood clotting. When you cut yourself or
damage a blood vessel, the platelets fill up the hole forming a ‘platelet plug’. The
second stage involves clotting factors (proteins in the blood), which then bind
everything together while the area heals.
How many platelets should I have?
The numbers of platelets, red cells and white cells in your blood are measured by a
test called the full blood count (FBC). Some people naturally have higher or lower
levels than others so doctors will talk about a ‘range’ of normal results. Your doctor will
be able to tell you what they consider normal at your hospital – the limits of the range
vary slightly between laboratories.
Your doctor will probably say something like ‘more than 150 is normal’. The number
‘150’ really means ‘150 × 109 platelets per litre’, which is a bit of a mouthful. Hence,
your doctors and nurses will probably just say your platelets are 150 (or 50 or 20, for
example, if they are low). Put another way ‘150’ actually means that every millilitre (mL)
of your blood contains 150,000 platelets and ‘20' still means you have 20,000 platelets
in every mL.
For more information about this and other blood tests please ring our helpline
(0808 808 5555).
What is meant by thrombocytopenia?
Thrombocytopenia means having low platelets in your bloodstream. Put another way, it
means the number of platelets on your FBC is below the ‘normal range’. Someone who
has low platelets (thrombocytopenia) is said to be ‘thrombocytopenic’.
What causes low platelets in people with lymphoma?
The main reasons for having low platelets in people with lymphoma are:
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the effect of lymphoma in the bone marrow, if there is any – it may take up the
space in the bone marrow normally used to make the healthy blood cells the body
needs
the effect of chemotherapy treatment on megakaryocytes (the cells in the bone
marrow that make the platelets)
platelets being used up or removed from the blood too fast for the bone marrow to
keep up due to:
-having an enlarged spleen (splenomegaly), where the platelets ‘pool’ (collect)
instead of being in the bloodstream
-an antibody that attacks the platelets, a condition known as ‘immune
thrombocytopenia’ (see next page).
Extra tests may be needed to find out what the reason is.
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Chemotherapy
The main aim of chemotherapy is to kill lymphoma cells but the treatment damages
normal healthy cells that are dividing too. Until the megakaryocytes recover, fewer
platelets are made and the number in the blood drops.
If you are going to develop low platelets following chemotherapy, it usually starts
about 6–10 days after the start of your treatment. How low your platelets will go and
for how long will depend on:
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how intensive (strong) your type of chemotherapy is
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whether you had lymphoma in the bone marrow before you started treatment.
Radiotherapy is usually aimed at only one area of the body, so it will not normally
affect too much bone marrow. Because of this, it would be unusual for radiotherapy
alone to cause very low platelets.
Immune thrombocytopenia
In some people with lymphoma, most often one of the low-grade types, the body’s
immune system can react against its own cells. It does this by forming autoantibodies
(antibodies are proteins that help kill off disease-causing cells or organisms such as
bacteria). Autoantibodies can also be produced by people who have no other illness
and may cause many different diseases.
Autoantibodies against blood cells are more common in people with low-grade
lymphoma, particularly small lymphocytic lymphoma (SLL) – also known as chronic
lymphocytic leukaemia (CLL).
When immune thrombocytopenia (often shortened to ITP) occurs, the autoantibodies
that are being produced stick to the platelets. When these platelets pass through the
spleen, the antibody triggers the spleen to remove the platelets. If lots of platelets are
being removed by the spleen, the bone marrow will not be able to make enough new
platelets to keep up. As a result, there will be fewer platelets in the bloodstream.
What will happen to me if I have low platelets?
Having low platelets will not make you feel any different. In fact, most people who
have a platelet count that is below the normal range will have no problems at all. This
is because the body has a built-in reserve: you have many more platelets than you
really need for normal life.
With platelets above 50 you shouldn’t notice anything at all. The fewer platelets you
have though, the longer it will take to form a blood clot if you injure yourself. Also,
with fewer platelets you become more at risk of bruising and bleeding without an
obvious cause.
If your platelet count is below 20, you will probably notice that you are bruising more
and it is possible you may start to bleed. Bleeding without an obvious cause only
becomes likely if your platelets are less than 10.
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The symptoms you may notice if your platelets are very low include:
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nosebleeds
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mouth or gum bleeding
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heavy periods in women
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blood in your urine
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bleeding from the bowel – this can be obvious blood or may just make your stools
black in colour
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easy bruising
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purpura (little red skin spots), especially on the legs
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tiredness – if bleeding goes unnoticed and causes anaemia.
Why are people with lymphoma more prone to bleeding?
There are other possible reasons why people with lymphoma may be more prone to
bleeding. These include:
●
having another problem with their blood clotting, for example lymphoma in the liver
might mean fewer clotting factors are made
●
being on other drugs that affect blood clotting, such as aspirin, heparin or warfarin
●
being feverish as this tends to use up platelets faster and make bleeding worse.
What should I do if I start bleeding?
The key to avoiding serious problems due to low platelets is to get in touch with your
hospital quickly if you start bleeding. You should be given contact phone numbers
to use at any hour of the day or night and at weekends. Many chemotherapy units
provide cards with information about the regimen you are on, as well as information
and leaflets to show your GP or district nurse if needed. These will cover various
symptoms, including bleeding.
If you develop any of the symptoms described above you should contact someone
for advice. If you are bruising easily or feel tired, a blood test might be arranged for
you, perhaps on the next day. If you are bleeding, you might need to be seen more
urgently. If the advice you receive is that you should attend the hospital, you must go.
Do not wait at home letting the situation worsen. If your platelets are very low and
you are bleeding, the situation will only get worse. It is always better to be checked
over and have treatment early if needed.
How are low platelets treated in people who have
lymphoma?
Many people who have times when their platelets are low because of chemotherapy
need no treatment at all. This is because their bone marrow stops working only briefly
and their platelets quickly return to a safe level. As a result, their risk of bleeding is
raised only slightly and just for a very short time.
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Platelet transfusion
When necessary, platelets can be replaced with a platelet transfusion. This is similar
to a blood transfusion given for anaemia, except it only takes about half an hour. As
with other blood transfusions, a huge effort goes into making the transfusion safe, so
it is rare to have any problems.
Unlike red cells, transfused platelets do not last long in the bloodstream. They also do
not return the platelet count to normal but simply raise it enough to reduce the risk of
bleeding. Therefore platelet transfusions are generally limited to the following groups:
●
people who are actively bleeding and have a low platelet count
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people who have a very low platelet count, which makes it likely they will bleed
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people who have a low platelet count and need to undergo an operation or other
medical procedure.
Changes to other drugs
If you are on warfarin, heparin or aspirin, the dosage of these drugs might need to be
adjusted if you develop bleeding or if your platelets are also low, especially if you have
liver problems too. Occasionally, other treatments to help your blood clot, such as
vitamin K or an infusion of fresh frozen plasma (FFP), might also be required.
Treatments for immune thrombocytopenia
If your platelets are being destroyed because you are making autoantibodies to them
(see page 3) platelet transfusions will not help. Instead your doctors will try to reduce
the amount of autoantibody being made. This is usually done, at least at first, by giving
you treatment with steroids, often prednisolone. The dose of steroid will be high to
begin with and you may be given another drug to protect your stomach too.
Once your platelets are no longer being destroyed, the dose of steroid will be
lowered steadily. Treating your lymphoma will also help to stop the autoantibodies
being made. The antibody therapy rituximab (MabThera®) is often used, with or without
chemotherapy, as it both reduces autoantibody production and kills the lymphoma cells.
For further information about steroids or antibody therapy, please ring our
helpline (0808 808 5555).
How can I reduce my risk of bleeding
Doing the following may help you avoid injury, so making you less likely to bleed if you
have low platelets:
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avoid high-impact sports, such as long-distance running, and contact sports, such
as rugby
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take care when gardening or doing DIY
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take care when using knives to prepare food
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avoid blowing your nose too hard or too often
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be careful when shaving – using an electric razor is preferable to wet shaving
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brush your teeth regularly but gently using a soft-bristled toothbrush (eg a child’s
toothbrush)
avoid flossing your teeth if it causes bleeding and your platelets are low.
Acknowledgement
We are grateful to Dr Paul Revell, consultant haematologist at Stafford Hospital, for his
assistance in the writing and reviewing of this article.
Useful sources of further information about having low platelets and
bleeding
Macmillan Cancer Support
89 Albert Embankment
London SE1 7UQ
 0808 808 0000 (Monday–Friday, 9am–8pm)
 Order line for booklets 0800 500 800
 via website
www.macmillan.org.uk
CancerHelp UK
The patient information section of Cancer Research UK
Angel Building
407 St John Street
London EC1V 4AD
 0808 800 4040 (Monday–Friday, 9am–5pm)
 via website
www.cancerresearchuk.org
Selected references
The full list of references is available on request. Please contact us via email
([email protected]) or telephone 01296 619409 if you would like a copy.
UK Blood Transfusion & Tissue Transplantation Services. Guidelines for the Blood
Transfusion Services in the UK. 7th edition. 2005. www.transfusionguidelines.org.uk
(accessed 20 November 2012).
Estcourt LJ, et al. Prophylactic platelet transfusion for prevention of bleeding in patients
with haematological disorders after chemotherapy and stem cell transplantation.
Cochrane Database of Systematic Reviews, 2012. 5: CD004269.
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How we can help you
We provide:
a freephone helpline providing information and emotional support  0808 808 5555
(9am–6pm Mondays–Thursdays; 9am–5pm Fridays) or  [email protected]
●
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information sheets and booklets about lymphoma (free of charge)
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a website with forums – www.lymphomas.org.uk
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the opportunity to be put in touch with others affected by lymphoma through our
buddy scheme
a nationwide network of lymphoma support groups.
How you can help us
We continually strive to improve our information resources for people affected by lymphoma
and we would be interested in any feedback you might have on this article. Please visit
www.lymphomas.org.uk/feedback or email [email protected] if you have
any comments. Alternatively please phone our helpline on 0808 808 5555.
We make every effort to ensure that the information we provide is accurate but it
should not be relied upon to reflect the current state of medical research, which is
constantly changing. If you are concerned about your health, you should consult
your doctor.
The Lymphoma Association cannot accept liability for any loss or damage resulting
from any inaccuracy in this information or third party information such as
information on websites which we link to. Please see
our website (www.lymphomas.org.uk) for more
information about how we produce our information.
© Lymphoma Association
PO Box 386, Aylesbury, Bucks, HP20 2GA
Registered charity no. 1068395
Updated: April 2013
Next planned review: 2015
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