Navigating the Hemostatic Balance: Anticoagulation and Antiplatelet Therapy in Patients with Thrombocytopenia
Year: 2026
Type: article
Abstract: Background: Thrombocytopenia is traditionally perceived as a bleeding-predominant condition; however, growing evidence indicates that many thrombocytopenic states are paradoxically associated with an increased risk of venous and arterial thrombosis. This dual hemostatic derangement poses major therapeutic challenges when anticoagulant or antiplatelet therapy is indicated, particularly in complex settings such as cancer-associated thrombosis, immune thrombocytopenia, and advanced liver disease. Methods: We conducted a narrative review of the literature published between January 2021 and May 2025 using PubMed and guideline repositories. Search terms included thrombocytopenia, anticoagulation, antiplatelet therapy, cancer-associated thrombosis, immune thrombocytopenia, and cirrhosis. International guidelines from ASH, ISTH, ASCO, EHA, ESC, and AHA were prioritized. Evidence was synthesized to define platelet-based safety thresholds and disease-specific management strategies. Results/Discussion: Thrombocytopenia does not uniformly confer protection against thrombosis. Platelet activation, endothelial dysfunction, inflammatory signaling, impaired fibrinolysis, and procoagulant microparticles contribute to a prothrombotic milieu despite reduced platelet counts. Most guidelines support full-dose anticoagulation at platelet counts ≥ 50 × 109/L, with dose modification between 25 and 50 × 109/L and treatment interruption below 25 × 109/L, depending on thrombotic risk. Antiplatelet therapy requires stricter individualization, particularly regarding dual antiplatelet therapy. Conclusions: Management of antithrombotic therapy in thrombocytopenic patients requires a dynamic, individualized approach balancing ischemic and bleeding risks. Pragmatic algorithms may guide clinical decision-making while prospective data remain limited.
Source: Journal of Clinical Medicine
DOI: 10.3390/jcm15062273
Authors: María-Eva Mingot-Castellano, María Teresa Álvarez Román, Jose María Bastida, Nora Butta, Gonzalo Caballero Navarro, Mariana Canaro Hirnyk, Laura Entrena Ureña, Maria del Carmen Gómez del Castillo Solano, Andres Ramirez Lopez, Blanca Sánchez González, David Valcarcel Ferreira, Cristina Pascual Izquierdo
Institutions: Consejo Superior de Investigaciones Científicas, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Hospital Universitario La Paz, Hospital La Paz Institute for Health Research, Universidad Autónoma de Madrid, Universidad de Salamanca, Complejo Hospitalario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Hospital Universitario Miguel Servet, Hospital Universitario Son Espases, Hospital Universitario Virgen de las Nieves, Hospital Universitario Lucus Augusti, Complejo Hospitalario Universitario de Toledo, Hospital Universitario de Toledo, Parc de Salut, Vall d'Hebron Hospital Universitari, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón
Language: English
Subfield: Hematology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,137
OpenAlex ID: W7138046565