How is coagulopathy treated in patients with acute promyelocytic leukemia (APL)?

Updated: Jul 02, 2019
  • Author: Sandy D Kotiah, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

Answer

Intracerebral and pulmonary hemorrhages are the most frequent causes of early death in patients with APL, both before intiation of treatment and shortly afterward. Thrombotic complications occur less commonly. Consequently, measures to counteract coagulopathy,  as follows, should be started immediately [1] :

  • Montior activated partial thromboplastin time and thrombin time, as well as levels of fibrinogen and fibrinogen-fibrin degradation products, at least daily and more frequently if necessary.
  • Transfuse fibrinogen and/or cryoprecipitate, platelets, and fresh frozen plasma immediately upon suspicion of APL, then daily or more than once a day if needed, to maintain the fibrinogen concentration above 100-150 mg/dL, the platelet count above 30– 50×10 9 /L, and the international normalized ratio (INR) below 1.5.
  • Continue supportive treatment during induction therapy until all clinical and laboratory signs of coagulopathy have resolved.
  • Because of the high risk of hemorrhagic complications, avoid central venous catheterization, lumbar puncture, and other invasive procedures (eg, bronchoscopy) before and during remission induction therapy.
  • The benefit of using heparin, tranexamic acid, or other anticoagulant or antifibrinolytic agents to reduce the hemorrhagic and thrombotic risk associated with the coagulopathy before and during remission induction therapy remains questionable. 

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