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LETTER TO EDITOR
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 180-181

Platelet-rich plasma protocols can potentiate vascular emboli: Establishing risks and benefits to the patient before performing the procedure


Department of Rehabilitation Medicine, Singapore General Hospital, 169608, Singapore

Date of Submission20-Aug-2019
Date of Decision20-Sep-2019
Date of Acceptance22-Sep-2019
Date of Web Publication13-Dec-2019

Correspondence Address:
Dr. Tan Yeow Leng
Department of Rehabilitation Medicine, Singapore General Hospital, Outram Road, 169608 Singapore
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_60_19

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How to cite this article:
Leng TY. Platelet-rich plasma protocols can potentiate vascular emboli: Establishing risks and benefits to the patient before performing the procedure. J Int Soc Phys Rehabil Med 2019;2:180-1

How to cite this URL:
Leng TY. Platelet-rich plasma protocols can potentiate vascular emboli: Establishing risks and benefits to the patient before performing the procedure. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2020 Feb 19];2:180-1. Available from: http://www.jisprm.org/text.asp?2019/2/4/180/272896



Sir,

The case report in your esteemed journal by Jayaram et al. titled “Platelet-Rich Plasma Protocols Can Potentiate Vascular Emboli: Contraindications to Platelet-Rich Plasma (PRP)” has caught my attention.[1] I wish to comment on understanding PRP treatment and managing clinical benefits and risks.

I agree with the authors that there remains uncertainty revolving antiplatelets' effects on PRP therapy. Gaps in the literature pertaining to the timing of PRP during antiplatelet therapy remain to be filled, and the International Cellular Medicine Society is working toward efforts to bridge these gaps.[2] It can be tricky to manage the periprocedural aspect of withholding antiplatelets in patients. These patients often need antiplatelets for secondary cardiovascular prevention. For various clinical and medicolegal reasons, physiatrists might consult another relevant specialist. While this practice is acceptable, the referring physiatrist should still be aware of the details of relevant drug pharmacokinetics. As Ramsook and Danesh had suggested, the key lies in understanding the pharmacokinetics of these antiplatelets or antithrombotic agents to guide clinicians in risk-and-benefit discussion with the patients.[3] Aspirin, for example, with an effect on platelets by irreversibly inhibiting cyclooxygenase for 8–9 days, should be withheld for about a week prior to PRP injection. Resuming aspirin after PRP therapy can be as early as 2 h. Clopidogrel, another example, should be discontinued 7 days prior to procedure. A summary of the recommendation of discontinuation of various drugs prior to treatment should be readily available in the physiatrist clinic.

Another area of research interest is whether the effects of growth factor release by aspirin can be mitigated on PRP therapy by PRP sample activation prior to injection. Most of the patients who visit the musculoskeletal clinic are on low-dose aspirin for secondary cardiovascular prevention. Daily low dose of aspirin does reduce growth factor expression in freshly isolated PRP samples. The study by Jayaram et al. is steering toward the specifics on the use of arachidonic acids and thrombin for PRP sample activation prior to injection to maximize the therapeutic effect.[4] Therefore, clinicians need to be aware of the varied PRP sample preparations. At the same time, one needs to have up-to-date knowledge on future activation protocols and improving quality control of PRP.[5] With improved research on PRP, it is possible to anticipate new guidelines on the necessity to withhold antiplatelets and days to withhold prior to the actual day of treatment.

Lastly, effective communication of risks and benefits between physicians and patients is needed before a procedure. It is unclear in the case by Parthap et al. why the treating physician went ahead with the PRP therapy despite the patient not disclosing information about the cardiologist consultation. The sequence of events leading to PRP injection is beyond the discussion of this letter. Rather, a plausible suggestion is for the treating physician to consider using appropriate avenues to communicate directly with the cardiologist and patient. This will facilitate clinical decision-making when deciding to proceed with PRP treatment.

I congratulate Parthap et al. for bringing up this valuable case report with several learning points. With increasing popularity of regenerative medicine, physicians need to understand the pharmacokinetics of the treating agents, weigh the risk and benefits of treatment, communicate and decide treatment plans with patient, and keep abreast of the latest development in the field.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jayaram P, Yeh PC, Cianca J. Platelet-rich plasma protocols can potentiate vascular emboli: Contraindications to platelet-rich plasma. J Int Soc Phys Rehabil Med 2019;2:104-6.  Back to cited text no. 1
  [Full text]  
2.
International Cellular Medicine Society. Revision of the Best Practices Standards in Cell Based Medicine: Platelet Rich Plasma (PRP) Guidelines. International Cellular Medicine Society; 2012. Available from: http://www.cellmedicinesociety.org. [Last assessed on 2019 Nov 06].  Back to cited text no. 2
    
3.
Ramsook RR, Danesh H. Timing of platelet rich plasma injections during antithrombotic therapy. Pain Physician 2016;19:E1055-61.  Back to cited text no. 3
    
4.
Jayaram P, Yeh P, Patel SJ, Cela R, Shybut TB, Grol MW, et al. Effects of aspirin on growth factor release from freshly isolated leukocyte-rich platelet-rich plasma in healthy men: A prospective fixed-sequence controlled laboratory study. Am J Sports Med 2019;47:1223-9.  Back to cited text no. 4
    
5.
Tsujino T, Isobe K, Kawabata H, Aizawa H, Yamaguchi S, Kitamura Y, et al. Spectrophotometric determination of the aggregation activity of platelets in platelet-rich plasma for better quality control. Dent J (Basel) 2019;7. pii: E61.  Back to cited text no. 5
    




 

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