Management of Chemotherapy Induced Thrombocytopenia

Publication Date: October 10, 2023
Last Updated: November 14, 2023

Use of Platelet Transfusion for Severe CIT

We recommend empiric platelet transfusion for platelet count <10 x109 /L

We suggest platelet transfusion for serious bleeding (WHO grade 2 or higher) in patients with less severe thrombocytopenia (e.g., <50 x 109 /L)

We recommend that platelet transfusion not be administered prophylactically to maintain the platelet count to allow for full dose chemotherapy.

Thrombocytopenia Receptor Agonists for CIT in Solid Tumors

This subcommittee acknowledges the lack of high-quality data (phase 3 trials) demonstrating efficacy for TPO-RA in the management of CIT. As such, any guidance below regarding the use of TPO-RA in management of CIT should be considered suggestions (or weak recommendations).

  • If considering use of a TPO-RA, we suggest enrollment in a clinical trial as preference.
  • If unable to enroll in a clinical trial, we suggest consideration of a TPO-RA in the setting of inadequate platelet recovery at day 1 of a chemotherapy cycle to avoid chemotherapy dose reduction or a delay of 7 or more days. (Assuming adequate neutrophil and hemoglobin recovery.)
    • Potential use of a TPO-RA should be in patients with solid tumors where full dose chemotherapy is expected to achieve or maintain a clinically-relevant response. (Note, the use of TPO-RA has not been studied in an adjuvant setting.)
    • Goals of therapy for use of a TPO-RA should be to achieve an adequate platelet count to avoid reduced chemotherapy dose intensity in future cycles.
    • Once initiated, a TPO-RA should be continued for the duration of chemotherapy, with titration to the lowest dose to maintain a target platelet count between 100-200 x 109/L (or titrate to the platelet count to allow full relative dose intensity chemotherapy) at the beginning of each chemotherapy cycle.
  • When considering off-label use of TPO-RA (not in the setting of a clinical trial), we recommend use of romiplostim over other TPO-RAs.
  • We recommend against the initiation of TPO-RA during chemotherapy nadir of index episode as there are no data to indicate shortening of the depth or duration of an acute nadir, and there are no data on safety in this setting.

Thrombopoietin Receptor Agonists for in Acute Myeloid Leukemia or High-Risk Myelodysplasia

We recommend against the use of TPO-RA for the management of CIT in acute myeloid leukemia or high-risk myelodysplasia outside of a clinical trial.

Thrombopoietin Receptor Agonists in Lymphoma

We recommend against the use of TPO-RA for the management of CIT during therapy for lymphoma outside of a clinical trial.

Tranexamic Acid for Chemotherapy Induced Thrombocytopenia

We recommend against the use of prophylactic tranexamic acid for prevention of hemorrhage in CIT.

Recommendation Grading


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Management of Chemotherapy Induced Thrombocytopenia

Authoring Organization

Publication Month/Year

October 10, 2023

Last Updated Month/Year

November 20, 2023

Document Type


Country of Publication


Document Objectives

Thrombocytopenia is a common adverse effect of chemotherapy. The development of chemotherapy induced thrombocytopenia (CIT) is influenced by cancer type and therapy, occurring in approximately one-third of patients with a solid tumor diagnosis and half of all patients with a hematologic malignancy. CIT may complicate the administration of chemotherapy leading to therapeutic delays or dose reductions. This guidance document, presented by the ISTH Subcommittee on Hemostasis and Malignancy, provides a comprehensive summary of the evidence and offers direction on the use of thrombopoietin receptor agonists (TPO-RAs) in various settings of CIT, including solid tumors, acute myeloid leukemia, stem cell transplant, and lymphoma. Studies have shown that TPO-RAs can improve platelet counts in CIT, but the clinical benefits of TPO-RA in terms of reducing bleeding, limiting platelet transfusion, or avoiding chemotherapy delay or dose reduction are uncertain. Further research is needed to optimize the selection of appropriate indications and study design to manage thrombocytopenia following chemotherapy.

Inclusion Criteria

Male, Female, Adult, Infant

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D013921 - Thrombocytopenia


chemotherapy, thrombocytopenia, Chemotherapy Induced Thrombocytopenia, thrombopoietin

Source Citation

Gerald Soff, Avi Leader, Hanny Al-Samkari, Anna Falanga, Anthony Maraveyas, Kristen Sanfilippo, Tzu-Fei Wang, Jeffrey Zwicker, Management of Chemotherapy Induced thrombocytopenia: Guidance from the ISTH Subcommittee on Hemostasis & Malignancy, Journal of Thrombosis and Haemostasis, 2023, ISSN 1538-7836,

Supplemental Methodology Resources

Data Supplement, Evidence Tables


Number of Source Documents
Literature Search Start Date
January 1, 1995
Literature Search End Date
March 1, 2022