Efficacy and safety of perioperative thrombopoietin receptor agonists in patients with immune thrombocytopenia and thrombocytopenia secondary to chronic liver disease undergoing elective procedures: A systematic review and meta-analysis.

Thrombocytopenia, a common side effect of chronic liver disease (CLD), increases bleeding risk during invasive procedures. Thrombopoietin receptor agonists (TPO-RAs) offer an effective alternative to platelet transfusions. A systematic review and meta-analysis assessed the efficacy and safety of TPO-RAs in thrombocytopenia patients undergoing elective procedures. A systematic search (PubMed, Google Scholar, Cochrane Library, up to August 2024) evaluated perioperative thrombopoietin receptor agonists in patients with thrombocytopenia undergoing elective procedures. Primary and secondary outcomes included platelet count ≥50 x 10^9/L, bleeding/thrombotic events, platelet transfusions, adverse effects, rescue treatment, discontinuation, death, and serious adverse effects, analyzed via random-effects model. This meta-analysis synthesized evidence from nine trials and 1,409 patients (819 TPO-RAs vs 590 placebo; mean age ~59 years). TPO-RAs significantly increased the likelihood of achieving platelet counts ≥50×10⁹/L compared with placebo (RR 3.93, 95% CI 2.24-6.90; p<0.00001). They also reduced the need for preoperative platelet transfusions (RR 0.34, 95% CI 0.27-0.44; p<0.00001) and lowered the risk of surgical bleeding (RR 0.64, 95% CI 0.49-0.85; p=0.002). In contrast, no statistically significant differences were observed for thrombotic events (RR 1.24, 95% CI 0.57-2.67; p=0.59), treatment-emergent adverse events (RR 0.99, 95% CI 0.89-1.09; p=0.83), study drug discontinuation (RR 0.74, 95% CI 0.32-1.70; p=0.47), rescue treatment use (RR 0.82, 95% CI 0.34-2.03; p=0.67), all-cause mortality (RR 1.23, 95% CI 0.35-4.35; p=0.75), or serious adverse events (RR 1.13, 95% CI 0.70-1.84; p=0.62). TPO-RAs raise platelet counts and reduce transfusions in CLD patients undergoing invasive procedures. However, close monitoring for thrombotic risks is necessary, and further research is needed to optimize dosing.