Do we have to worry for thrombocytopenia during treatment of hepatitis C.

bopag increases platelet numbers in thrombocytope-nic patients with HCV infection and cirrhosis, allowing for effective antiviral therapy. Gastroenterology 2014; 146: 442-52. Thrombocytopenia is defined as platelet count being <150.000 cells/μL. A platelet count of 50.000 to 75.000/μL means moderate thrombocytopenia and a platelet count below 50.000 indicates severe throm-bocytopenia. It is common among individuals with HCV-associated chronic hepatic conditions and a significant problem, which requires dose reduction in or discontinuation of antiviral treatment and reduces sustained viral response to therapy. The prevalence of thrombocytopenia was reported as 0.16% to 45.4% (24% in average) in chronic hepatitis C (HCV) (1). In chronic HCV, thrombocytopenia may develop due to bone marrow inhibition, platelet sequestration in splenomegaly, reduced hepatic thrombopoietin production , as well as autoimmune causes. In addition, antiviral (AV) therapy (particularly pegylated interferon (PEG) + ribavirin (RBV)) induces bone marrow suppression , further reducing platelet counts (2). To initiate AV therapy, platelet count should be above the minimal threshold count (PEG-2a; >90.000, PEG-2b; >100.000), and, where platelet count is ≤50.000, a reduction in the dose will be necessary (3). In HCV and secondary cirrhosis, platelet infusion, splenic artery embolisation, splenectomy and TIPS have been used in the treatment of thrombocytopenia. can also stimulate thrombopoiesis. In a phase II study published in 2007, 30-75mg of eltrombopag given as a single daily dose for the commencement of PEG-based therapies was shown to increase platelet counts in 71-91% of the patients with HCV-associated hepatic cirrhosis plus thrombocytopenia (4). Eltrombopag (Pro-macta; GlaxoSmithKline, Research Triangle Park, NC) is a FDA-approved non-peptide thrombopoietin receptor agonist which corrects thrombocytopenia and thereby facilitates initiation and maintenance of INF-based treatments in HCV. In this study published in the February 2014 issue of the Gastroenterology journal, Afdhal et al. (5) have reported that eltrombopag elevated platelet counts and thus contributed to the efficacy of antiviral therapy in patients with HCV and HCV-associated cirrhosis. Patients with HCV and thrombocytopenia (<75,000/μL) from 23 countries and 150 centres joined this study by receiving ≤9 weeks of treatment with eltrombopag (25-100mg/day) as per ENABLE-1 (Eltrombopag to Initiate and Maintain Interferon Antiviral Treatment to Benefit Subjects with Hepatitis C-Related Liver Disease) (n ¼ 715, PEG-2a) and ENABLE-2 (n ¼ 805, PEG-2b) protocols. Patients who attained 95% and 94% of the threshold platelet count in ENABLE-1 and ENABLE-2, respectively, were randomized in a double-blind fashion and with a ratio of 2:1 to receive AV treatment (24 or …