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Thrombocytopenia (low platelets)

Platelets are the part of blood that stops bleeding. Thrombocytopenia means that you have
fewer platelets than you should have. People with lymphoma sometimes have
thrombocytopenia because of the lymphoma itself or as a side effect of the treatment they are
having. This can put them at a higher risk of bleeding.

What is thrombocytopenia? (page 1)

How are platelets counted? (page 2)
Why are platelets important? (page 2)
What causes thrombocytopenia in people with lymphoma? (page 2)
What other factors can make people with lymphoma prone to bleeding? (page 4)
What are the symptoms of thrombocytopenia? (page 4)
How is thrombocytopenia treated? (page 6)
How can you reduce your risk of bleeding? (page 7)
Further support (page 8)

What is thrombocytopenia?
Thrombocytopenia is a shortage of platelets. If you dont have a normal number of platelets,
doctors say that you are thrombocytopenic.

Platelets are made in the bone marrow (the spongy centre of some bones). They develop
from huge cells in the bone marrow called megakaryocytes. Usually platelets stay in the
bloodstream for about 10 days before they are removed by the spleen. The bone marrow
works all the time to make new platelets. It works harder if platelets are needed to stop
bleeding somewhere in your body.

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How are platelets counted?
The number of platelets in your blood is measured by a test called the full blood count (FBC).
Doctors talk about a range of normal results because some people naturally have higher or
lower levels than others. Different hospitals use slightly different ranges. Your doctor should
tell you what is considered normal at your hospital. They are likely to say something like more
than 150 is normal. The 150 means 150 million platelets per millilitre (mL) of blood. This is a
bit of a mouthful so doctors and nurses talk about platelets being 150 (or 50 or 20, for
example, if they are low).

We have more information about blood tests and the full blood count, which you can read on
our website at www.lymphomas.org.uk. You can also print this information at home or ask
our helpline to send you a copy. Please email us at information@lymphomas.org.uk or call
on 0808 808 5555.

Why are platelets important?

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.

If you have a low number of platelets, it is harder for you to form a blood clot. This means you
may bleed for longer if you cut yourself. You may also bruise more easily than normal.

What causes thrombocytopenia in people with lymphoma?

Possible causes of low platelets when you have lymphoma are:

lymphoma in the bone marrow (page 2)

a side effect of treatments for lymphoma including chemotherapy and some of the
newer, targeted therapies (page 3)
platelets being used up or removed from the blood too fast for the bone marrow to keep
up, which may be caused by
having an enlarged spleen (splenomegaly) (page 3)
platelets being destroyed by an antibody that attacks them (immune
thrombocytopenia) (page 4).

Lymphoma in the bone marrow

If lymphoma cells are in the bone marrow, they take up space that is normally used to
produce healthy blood cells. This can lower the number of platelets your bone marrow makes,
meaning you have fewer platelets and become thrombocytopenic.

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Lymphoma in the bone marrow is seen more often in people with low-grade lymphomas
but some high-grade lymphomas can affect the bone marrow too.

This type of thrombocytopenia often begins to improve once treatment for the lymphoma has
started to work.

A side effect of treatment

Although the aim of chemotherapy is to kill the lymphoma cells, a side effect of many types of
chemotherapy is the destruction of some healthy cells. This can affect the megakaryocytes in
the bone marrow that would normally make new platelets. If the number of new platelets
made doesnt meet the number needed in the bloodstream, the platelet count falls.

If it is going to occur, thrombocytopenia usually starts about 610 days after the start of
chemotherapy. Not all treatments result in thrombocytopenia. How low your platelet levels go
after treatment and for how long depends on:

how strong your chemotherapy is

whether you had lymphoma in the bone marrow before you started treatment.

Some of the newer targeted therapies can cause thrombocytopenia and increase the risk of
bleeding. Ibrutinib (Imbruvica) may cause bleeding because of its effect on the way platelets
work, without affecting their number. Because of this, it isnt usually given to people who are
taking drugs to thin the blood, such as warfarin. Bortezomib (Velcade),
obinutuzumab (Gazyvaro) and lenalidomide (Revlimid) can also cause low platelet levels.

Radiotherapy doesnt normally have much of an effect on the bone marrow. It doesnt usually
cause low platelet levels on its own.

We have more information about types of treatment for lymphoma, which you can read on our
website at www.lymphomas.org.uk. You can also print this information at home or, if you
prefer, our helpline can send you copies. Please email at information@lymphomas.org.uk
or call on 0808 808 5555.

Splenomegaly

As well as being found in the blood, some of the bodys platelets are always found in the
spleen. If the spleen is bigger than normal (splenomegaly), there is space in it for more
platelets. As a result, the platelets tend to collect in the spleen, leaving fewer than normal in
the bloodstream.

Treatments that shrink the spleen may help if this is the cause of your thrombocytopenia.
Sometimes the spleen is removed (splenectomy). This may be done to treat the lymphoma
but usually helps improve platelet levels too.

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Immune thrombocytopenia

Sometimes the bodys immune system starts to make antibodies against cells within the body.
These antibodies are known as autoantibodies.

If the autoantibodies stick to platelets, these platelets are removed when they pass through
the spleen. When the bone marrow cant make new platelets fast enough to replace the ones
lost, thrombocytopenia develops. This type of thrombocytopenia is known as immune
thrombocytopenic purpura (ITP). It happens more often in people with low-grade lymphomas,
such as chronic lymphocytic leukaemia (CLL).

We have more information about the lymphatic and immune systems, which you can read on
our website at www.lymphomas.org.uk. You can also print this information at home or, if you
prefer, our helpline can send you copies. Please email at information@lymphomas.org.uk
or call on 0808 808 5555.

What other factors can make people with lymphoma

prone to bleeding?
In addition to thrombocytopenia, people with lymphoma may be more likely to bleed for other
reasons. These include:

having another problem with 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
having a fever (high temperature) as this tends to use up platelets faster and make
bleeding worse.

What are the symptoms of thrombocytopenia?

Having low platelets does not make you feel any different. Most people who have a platelet
count that is below the normal range have no symptoms at all. This is because the body has a
built-in reserve with many more platelets than are needed for day-to-day life.

If your platelet count falls to very low levels, symptoms become more likely. A general guide to
what you might expect with different numbers of platelets is:

slightly low platelets (above 50) probably no symptoms at all

low platelets (2050) you may bruise more easily and bleed for longer if you
cut yourself
very low platelets (1020) you will probably bruise more easily, bleed for longer if you
cut yourself and may start to notice bleeding even without an obvious cause
extremely low platelets (below 10) you are at risk of bleeding, even without an
obvious cause.

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The bleeding you may notice if your platelets are very low includes:

nosebleeds
mouth or gum bleeding
heavy periods in women
blood in urine
bleeding from the bowel this can be obvious blood or may make your stools black
in colour.

As well as bruising more easily, you may also notice purpura (petechia). These are small red
or purple spots on the skin (often on the legs) or on the lips or in the mouth. They can appear
temporarily when platelets are very low.

If bleeding goes unnoticed, it can also cause anaemia.

What should you do if you start bleeding?

The key to avoiding serious problems caused by low platelets is to get in touch with your
hospital quickly if you start bleeding.

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Let your medical team know if you develop any of the mentioned symptoms. If you are
bruising easily or are feeling tired, your doctor may arrange a blood test. If you are bleeding,
they may want to see you more quickly in the hospital. Remember, 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 is thrombocytopenia treated?

Many people who have times when their platelets are low because of chemotherapy need no
treatment at all. Their bone marrow stops working only briefly and their platelets quickly return
to a safe level. As a result, they have a higher risk of bleeding for a very short time only.

For those who experience bleeding, treatments can include:

changes to types and doses of other drugs you are taking

platelet transfusions.

Platelet transfusions dont work well for immune thrombocytopenic purpura (ITP). Instead,
treatment for ITP aims to lower the levels of the autoantibody.

There are drugs that boost the megakaryocytes to make more platelets (thrombopoietin
receptor agonists). These are similar to the growth factors G-CSF (used to raise the white
blood cell count) and erythropoietin (used to treat anaemia). They are sometimes used to treat
ITP. At present, they are not used to treat thrombocytopenia that is caused by chemotherapy.

Changes to other drugs

If you are on warfarin, heparin or aspirin and develop bleeding, you might need to stop taking
the blood thinner or lower its dose. This might also be done if your platelets are low, especially
if you have liver problems too. Your medical team will tell you if you need to make changes;
always check with them before you stop, start, or change the dose of your drugs.

Occasionally, other treatments to help your blood clot, such as vitamin K or an infusion of
fresh frozen plasma (FFP), might be needed.

Platelet transfusion

If you are bleeding and your platelets are low, you may be given a platelet transfusion. This is
similar to a blood transfusion given for anaemia, except it takes only about half an hour.
Platelet transfusions are as safe as other blood transfusions.

The platelets that are given do not make the platelet count normal again. Instead, they stop
any bleeding thats already occurred or lower the risk of further loss of blood. Because the
platelets get used up, the effect only lasts for a few days.

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Platelet transfusions are usually given only to:

people who are actively bleeding and have a low platelet count
people who have an extremely low platelet count, which makes them likely to bleed
people who have a low platelet count and need to have an operation or another
significant medical procedure.

Treatments for immune thrombocytopenia

If your thrombocytopenia is caused by autoantibodies destroying your platelets, platelet

transfusions will not help. Instead, the treatment of this type of thrombocytopenia aims to
reduce how much autoantibody is being made. This is usually done, at least at first, by giving
you steroids, often prednisolone. The dose of steroid is high to begin with and this may cause
irritation to your stomach. You may be given another drug to protect your stomach.

Once your platelets are no longer being destroyed, the dose of steroid is lowered.

Treating your lymphoma may also help to stop the autoantibodies being made. Rituximab
(MabThera), with or without chemotherapy, tends to reduce the number of autoantibodies as
well as kill the lymphoma cells.

We have more information about steroids and rituximab, which you can read on our website at
www.lymphomas.org.uk. You can also print this information at home or, if you prefer, our
helpline can send you copies. Please email at information@lymphomas.org.uk or call on 0808
808 5555.

How can you reduce your risk of bleeding?

You cannot stop yourself becoming thrombocytopenic, but the following advice may make you
less likely to bleed if you have low platelets (your medical team should tell you what is
sensible for you):

avoid high-impact sports (eg long-distance running) and contact sports (eg rugby)
wear gloves, long sleeves and long trousers to help protect you from scratches and cuts
when gardening or doing DIY
take extra care to avoid cutting yourself when using knives to prepare food
avoid blowing your nose too hard or too often
use an electric razor over wet shaving
brush your teeth regularly but gently using a soft-bristled toothbrush (eg a
childs toothbrush)
avoid flossing your teeth if it causes bleeding.

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Further support
ITP support association is a charity that supports those affected by Immune
Thrombocytopenia (Idiopathic Thrombocytopenic Purpura)

ITP Support Association

The Platelet Mission
Kimbolton Road
Bolnhurst
Bedfordshire
MK44 2EL

info@itpsupport.org.uk
www.itpsupport.org.uk

Sources used
These are a few of the sources we used to prepare this information. The full list of sources is
available on request. Please contact us by email at publications@lymphomas.org.uk or
phone on 01296 619409 if you would like a copy.

Norfolk D (ed). Handbook of Transfusion Medicine. 5th edition. 2013. The Stationery
Office, Norwich.

Crighton GL, et al. A therapeutic-only versus prophylactic platelet transfusion strategy for
preventing bleeding in patients with haematological disorders after myelosuppressive
chemotherapy or stem cell transplantation. Cochrane Database of Systematic Reviews, 2015.
9: Cd010981.

Kuter DJ. Managing thrombocytopenia associated with cancer chemotherapy. Oncology

(Williston Park), 2015. 29: 282294.

Visco C, et al. Autoimmune cytopenias in chronic lymphocytic leukemia. American Journal

of Hematology, 2014. 89: 10551062.

Acknowledgements
With thanks to Dr Paul Revell, member of our Medical Advisory Panel and formerly Consultant
Haematologist at Stafford Hospital, for reviewing this information.

We would also like to thank the members of our Reader Panel who gave their time to review
this information.

The images used in this information are provided by Science Photo Library.

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 Content reviewed: February 2016

Next planned review: February 2019

Updated: August 2016

LYMweb0055/Thrombo/2016v3

We continually strive to improve our resources for people affected by lymphoma and we
would be interested in any feedback you might have about this information. Please
visit www.lymphomas.org.uk/feedback or email publications@lymphomas.org.uk if you have
any comments. Alternatively please phone our helpline on 0808 808 5555.

If you have found this information useful and would like to help make it available to other
people coping with lymphoma, then please consider making a donation to support our work
at www.lymphomas.org.uk/donate. We rely totally on voluntary donations. Thank you.

Disclaimer

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