What is the role of phlebotomy in the treatment of polycythemia vera (PV)?

Updated: Sep 20, 2021
  • Author: Srikanth Nagalla, MD, MS, FACP; Chief Editor: Sara J Grethlein, MD, FACP  more...
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Phlebotomy (bloodletting) has long been the mainstay of therapy for polycythemia vera (PV). The object is to remove excess cellular elements, mainly red blood cells, to improve the circulation of blood by lowering the blood viscosity. Because phlebotomy is the most efficient method of lowering the hemoglobin and hematocrit levels to the reference range, all newly diagnosed patients are initially phlebotomized to decrease the risk of complications.

Patients can be phlebotomized once or twice a week to reduce the hematocrit to less than 45%. A randomized trial demonstrated a significant difference in the rate of thrombotic events and cardiovascular deaths (2.7% vs 9.8%) when the hematocrit goal was 45% versus 50%. [29] Patients with severe plethora who have altered mentation or associated vascular compromise can be bled more vigorously, with daily removal of 500 mL of whole blood.

Elderly patients with some cardiovascular compromise or cerebral vascular complications should have the volume replaced with saline solution after each procedure to avoid postural hypotension. The presence of elevated platelet counts, which may be exacerbated by phlebotomy, is an indication to use myelosuppressive agents to avoid thrombotic or hemorrhagic complications.

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