Indications for use of recombinant factor VIIa: a case study with implications for research

The purpose of this case study was to explore the current use of recombinant factor VIIa to control hemorrhage in the trauma patient. Despite aggressive blood product replacement and surgical intervention, uncontrolled bleeding and resultant coagulopathy are lethal to the trauma patient. What is the correlation between this drug and the hemorrhagic trauma patient? Quite simply--does it work? Curiosity may have killed the cat, but this case study clearly demonstrates the need for further research and satisfactory answers to questions illuminated by this case.

Hémorragie de la délivrance « menaçant la vie » et utilisation du facteur VII recombinant activé rFVIIa NovoSeven®

Postpartum haemorrhage remains a dangerous obstetrical complication, which is the main cause of maternal mortality in developing countries. The diagnosis must be immediate and its management is both medically and surgically in life-threatening haemorrhage. We present a case of a thirty-three-year-old woman who asked a pregnancy interruption for premature rupture of membranes at 21(th) gestational week for her second pregnancy; she underwent a caesarean section at term for her first pregnancy. She delivered vaginally and developed a postpartum haemorrhage with hemorrhagic shock which was resistant to medical, surgical and radiological management. We decided to use recombinant activated factor VII (rFVIIa, NovoSeven) as a final attempt to rescue the patient. During surgery, two intravenous bolus injections (60, 120 mug/kg) were successfully given with a control of bleeding and haemoglobin. The patient developed later a splenic thrombosis that can be related to either rFVIIa or to the hypovolemic shock or to the sepsis. Recombinant activated factor VII is an interesting and promising haemostatic agent in the management of life-threatening postpartum haemorrhage unresponsive to conventional treatment.

Recombinant-activated coagulation factor VIIa (NovoSeven®): current development

Recombinant activated coagulation factor VII (rFVIIa) was developed initially for treatment of patients with hemophilia and neutralizing antibodies ("inhibitors") to coagulation factors VIII or IX. Owing to the unique and selective mechanism of action of rFVIIa and encouraged by clinical experience with other circumstances of inadequate hemostasis, a broad development program has been pursued to test potential efficacy and evaluate safety of this biologic for indications other than hemophilia. This review summarizes the current development of rFVIIa, focusing on results of prospective, randomized clinical trials.

Recombinant activated coagulation factor VII and bleeding trauma patients

BACKGROUND

Recombinant activated coagulation factor VII (rFVIIa) is increasingly being administered to massively bleeding trauma patients. rFVIIa has been shown to correct coagulopathy and to decrease transfusion requirements. However, there is no conclusive evidence to suggest that rFVIIa improves the survival of these patients. The purpose of this study was to determine whether or not rFVIIa has an effect on the in-hospital survival of massively bleeding trauma patients.

METHODS

A retrospective cohort study was conducted from January 1, 2000 to January 31, 2005, at a Level I trauma center in Toronto, Canada. Inclusion criteria included trauma patients requiring transfusion of 8 or more units of packed red cells within the first 12 hours of admission. The primary exposure of interest was the administration of rFVIIa. Primary outcome was a 24-hour survival and secondary outcome was overall in-hospital survival.

RESULTS

There were 242 trauma patients identified who met inclusion criteria; 38 received rFVIIa. rFVIIa patients were younger, had more penetrating injuries, and fewer head injuries. However, rFVIIa patients required more red cell transfusions initially, and were more acidotic. Administering rFVIIa was associated with improved 24-hour survival, after adjusting for baseline demographics and injury factors. The odds ratio (OR) for survival was 3.4 (1.2-9.8). Furthermore, there was a strong trend toward increased overall in-hospital survival. The OR of in-hospital survival was 2.5 (0.8-7.6). Also, subgroup analysis of rFVIIa patients showed that 24-hour survivors required a slower initial rate of red cell transfusion (4.5 vs. 2.9 units/hr, p = 0.002), had higher platelet counts (175 vs. 121 [x10(-9)/L], p = 0.05) and smaller base deficits (7.1 vs. 14.3, p = 0.001) compared with rFVIIa patients who died during the first 24 hours.

CONCLUSION

rFVIIa may be able to improve the early survival of massively bleeding trauma patients. However, surgical control of massive hemorrhage still has primacy, as rFVIIa did not appear efficacious if extremely high red cell transfusion rates were required. Also, correction of acidosis and thrombocytopenia may be important for rFVIIa efficacy. Prospective studies are required.

Successful use of recombinant factor VIIa (NovoSeven) in children with compartment syndrome: two case reports

Compartment syndrome (CS) is an uncommon bleeding manifestation in patients with liver failure and end-stage renal disease (ESRD). Although prompt intervention is paramount in preventing the tissue necrosis and the permanent functional deficits that may be associated with untreated CS, the indications for initiating therapies for children with CS are not standardized. In this report, we present 2 children, one with ESRD and the other with liver failure, who have CS related to life-threatening bleeding complications and were treated with recombinant factor VIIa (rFVIIa). In conclusion, treatment decisions for patients with CS should be made on a case-by-case basis. The use of rFVIIa is an effective and safe treatment in children with liver failure and ESRD. Surgical treatment should be preferred in patients with CS. However, in patients who have a coagulation defect, the first priority is to correct the clotting deficiency. The use of rFVIIa is a treatment option in children with CS due to a coagulation defect.

Acquired hemophilia as a cause of primary postpartum hemorrhage

A 32-year-old primigravid woman developed acquired factor VIII inhibitor after delivery. She presented with postpartum hemorrhage and large hematoma in episiotomy site. Laboratory examinations showed markedly prolonged activated partial thromboplastin time, low levels of factor VIII (8%), and factor VIII inhibitor (2 Bethesda units). The bleeding was controlled successfully using combined treatment with factor VIII, intravenous immunoglobulin, steroids, and recombinant factor VIIa. Six months after delivery, factor VIII inhibitor was not present and factor VIII concentration increased to normal range. Acquired hemophilia is a life-threatening disorder. Precise screening of coagulation factors is essential for diagnosis of persisting postpartum hemorrhage.

Cost effectiveness of recombinant activated factor VII for the control of bleeding in patients with severe blunt trauma injuries in the United Kingdom

The aim of this study was to assess the lifetime cost effectiveness of recombinant activated factor VII vs placebo as adjunctive therapy for control of bleeding in patients with severe blunt trauma in the UK. We developed a cost-effectiveness model based on patient level data from a 30-day international, randomised, placebo-controlled Phase II trial. The data were supplemented with secondary data from UK sources to estimate lifetime costs and benefits. The model produced a baseline estimate of the incremental cost per life year gained with recombinant activated factor VII relative to placebo of 12 613 UK pounds. The incremental cost per quality adjusted life year gained was 18 825 UK pounds. These estimates are sensitive to the choice of discount rate and health state utility values used. Preliminary results suggest that relative to placebo, recombinant activated factor VII may be a cost-effective therapy to the UK National Health Service.

Recombinant factor VIIa in massive postpartum haemorrhage

Massive postpartum haemorrhage is a major cause of maternal and fetal morbidity and mortality. Management mainstays include transfusion therapy, uterotonic agents and surgery. The "off label" use of recombinant activated factor VII appears to have an evolving role in the management of massive postpartum haemorrhage refractory to conventional treatments. The current literature is reviewed.

Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion

Wider use of oral anticoagulants has led to an increasing frequency of warfarin-related intracerebral hemorrhage (ICH). The high early mortality of approximately 50% has remained stable in recent decades. In contrast to spontaneous ICH, the duration of bleeding is 12 to 24 hours in many patients, offering a longer opportunity for intervention. Treatment varies widely, and optimal therapy has yet to be defined. An OVID search was conducted from January 1996 to January 2006, combining the terms warfarin or anticoagulation with intracranial hemorrhage or intracerebral hemorrhage. Seven experts on clinical stroke, neurologic intensive care, and hematology were provided with the available information and were asked to independently address 3 clinical scenarios about acute reversal and resumption of anticoagulation in the setting of warfarin-associated ICH. No randomized trials assessing clinical outcomes were found on management of warfarin-associated ICH. All experts agreed that anticoagulation should be urgently reversed, but how to achieve it varied from use of prothrombin complex concentrates only (3 experts) to recombinant factor VIIa only (2 experts) to recombinant factor VIIa along with fresh frozen plasma (1 expert) and prothrombin complex concentrates or fresh frozen plasma (1 expert). All experts favored resumption of warfarin therapy within 3 to 10 days of ICH in stable patients in whom subsequent anticoagulation is mandatory. No general agreement occurred regarding subsequent anticoagulation of patients with atrial fibrillation who survived warfarin-associated ICH. For warfarin-associated ICH, discontinuing warfarin therapy with administration of vitamin K does not reverse the hemostatic defect for many hours and is inadequate. Reasonable management based on expert opinion includes a wide range of additional measures to reverse anticoagulation in the absence of solid evidence.

Use of recombinant activated factor VII in massive obstetric haemorrhage

Massive obstetric haemorrhage is a life-threatening emergency that remains a major cause of maternal mortality. Conventional management is aimed at optimising uterine tone, replacing circulating volume and blood products, and surgery to achieve haemostasis. Recently there have been numerous reports of the (unlicensed) use of recombinant activated factor VII in the management of major obstetric haemorrhage. We report our experience of using it in the treatment of major post-partum haemorrhage in four previously healthy parturients. The published reports of recombinant activated factor VII use in post-partum haemorrhage (unrelated to pre-existing coagulopathies) are compared.

The Role of Data and Safety Monitoring in Acute Trauma Resuscitation Research

BACKGROUND

The role of data and safety monitoring boards (DSMBs) in clinical research in acute trauma resuscitation is not well documented. Many of the difficulties conducting acute resuscitation research are exacerbated because multiinstitutional studies are needed to adequately power such research.

STUDY DESIGN

The purpose of the study was to demonstrate how a well-organized DSMB, explicitly required for these types of clinical trials by many funding agencies, can be a valuable resource in their safe and successful conduct by maximizing data integrity and striving to standardize care by monitoring the consistent and accurate collection of data and adherence to protocol. As an example, the work of an external DSMB in an international multicenter trial of recombinant activated coagulation factor VIIa (rFVIIa) in blunt and penetrating trauma patients is presented. The DSMB in this study was responsible for reviewing all serious adverse event (SAE) data, performing an extended review of SAEs, and reviewing results of analyses of 48-hour and 30-day mortality according to prespecified study stopping rules.

RESULTS

Application by the DSMB of uniform definitions of SAEs substantially improved the integrity of the study data and facilitated analysis of events, such as disseminated coagulopathy, pulmonary complications, and multiple organ failure. As a result of the DSMB's efforts, important insights were gained to guide site selection and conduct of future trials of rFVIIa in trauma-induced hemorrhage.

CONCLUSIONS

Based on our experience as members of the study DSMB and on a review of the literature, we recommend a strong role for DSMBs in multicenter trials in acute resuscitative care.

Successful use of recombinant activated FVII and aminocaproic acid in four neonates with life-threatening hemorrhage

Reports on the use of recombinant activated factor VII (rFVIIa) to counteract hemorrhagic shock in neonates and preterm infants are increasing. rFVIIa enhances thrombin generation in situations with impaired thrombin formation and, since thrombin has a crucial role in providing hemostasis, rFVIIa is regarded as a general hemostasis agent. Full thrombin generation is necessary for the formation of a stable fibrin plug resistant to premature fibrinolysis. Antifibrinolytic drugs are not recommended for the treatment of acute bleeding. We report four neonates (one with massive postsurgical hemorrhage after ileostomy and three with severe pulmonary hemorrhage in the course of mechanical ventilation for meconium aspiration syndrome, congenital heart disease and during postoperative resuscitation after cardiac surgery for congenital heart disease) who were successfully treated with multiple administration of rFVIIa (120 microg/kg per dose) and antifibrinolytic therapy - aminocaproic acid (100 mg/kg per dose). In a fibrinolytic environment therapeutic concentrations of rFVIIa may sometimes be insufficient to produce adequate amounts of thrombin necessary for stable clot structure. Laboratory data in three of our patients with pulmonary hemorrhage (low fibrinogen levels with slightly prolonged prothrombin time) supported this thesis, so we blocked fibrinolysis with aminocaproic acid and achieved a complete clinical and laboratory therapeutic effect.

Case report: management of life-threatening oropharyngeal bleeding with recombinant factor VIIa

PURPOSE

To report the use of recombinant factor VIIa (rFVIIa) for management of profuse oropharyngeal bleeding in a cirrhotic patient that nearly resulted in a 'cannot intubate, cannot ventilate' scenario.

CLINICAL FEATURES

A 42-yr-old woman with end-stage liver disease presented for orthotopic liver transplantation. She was dialysis dependent and had marked coagulopathy [international normalized ratio (INR) = 3.1], without evidence of active bleeding. Following uneventful induction of anesthesia, routine airway manipulation for tracheal intubation caused profuse upper airway bleeding making visualization of her airway by direct laryngoscopy impossible. Moreover, several further attempts at tracheal intubation along with the bleeding made manual ventilation progressively more difficult, nearly resulting in a 'cannot intubate, cannot ventilate' scenario. In an attempt to control the bleeding, rFVIIa 4.8 mg iv was administered. Within five minutes, her INR had decreased to 1.1, bleeding was markedly reduced, the vocal cords were successfully visualized using an anterior commissure laryngoscope, and intubation of the trachea was achieved with the use of a gum-elastic bougie. Postintubation examination of the airway showed several abrasions along the right oropharyngeal wall with minimal bleeding. The remainder of surgery and postoperative airway management were uneventful.

CONCLUSIONS

This report demonstrates that in the relatively uncommon setting of upper airway hemorrhage in a patient with pre-existing coagulopathy, rFVIIa can be effective in gaining rapid control of bleeding to facilitate visualization of the vocal cords and securing of the airway.

Audit of factor VIIa for bleeding resistant to conventional therapy following complex cardiac surgery

PURPOSE

There are an increasing number of anecdotal reports and trials of recombinant activated factor VII (rFVIIa) for bleeding during surgery. The reports of rFVIIa during cardiac surgery are limited. We report our experience using rFVIIa, in the operating room; to treat bleeding that prevented chest closure, despite appropriate conventional treatment, following complex cardiac surgery.

METHODS

Retrospective chart review, at an Australian University hospital and associated private hospital, of cardiac surgery patients given rFVIIa (usual dose 90 microg.kg(-1)). We used rFVIIa for bleeding that prevented closure of the chest despite administration of blood products, protamine, and surgical attempts to secure hemostasis.

RESULTS

Recombinant activated factor VII was administered on 55 occasions to 53 patients. Most patients had complex aortic or valve surgery. Median bypass time was 266 min. Before administering rFVIIa, patients received (median): packed red cells four units; platelets 15 units; fresh frozen plasma eight units; and cryoprecipitate ten units. After administering rFVIIa the median doses of donor blood products up to 12 hr after intensive care unit admission were: packed red cells one unit; platelets zero units; fresh frozen plasma zero units; and cryoprecipitate zero units. The decrease in doses of all blood products was significant (P < 0.001). We could not determine if rFVIIa played a role in significant mortality (19%) and morbidity (17%).

CONCLUSION

Use of rFVIIa in cardiac surgery may be effective, but definitive clinical trials are needed to clarify its role in clinical practice and safety. We present an rFVIIa guideline developed during the audit period.

Hematologic disorders in critically ill patients

Hematologic disorders are frequently encountered in the intensive care unit. Thrombocytopenia, often defined as a platelet count below 100,000/microL, is common in critically ill patients and may be associated with adverse outcomes. A systematic evaluation of clinical and laboratory findings is necessary to ascertain the cause of the thrombocytopenia and to determine the correct therapy. Recognition of heparin-induced thrombocytopenia (HIT) is particularly important, given the risk of thrombosis associated with this condition. Prompt cessation of all heparin products is required, and anticoagulation with a direct thrombin inhibitor is recommended if HIT is strongly suspected. Coagulopathies are also common in the critically ill, and are often due to vitamin K deficiency or disseminated intravascular coagulation (DIC). A careful history and interpretation of clotting studies are useful in defining the coagulation defect. Advances in understanding the pathogenesis of DIC have generated new treatment approaches, such as the use of recombinant activated protein C. Recombinant factor VIIa (rFVIIa) is a novel drug approved for use in patients with congenital hemophilia and inhibitors. Although its use as a hemostatic agent is currently being evaluated in several off-label scenarios, including trauma, intracerebral hemorrhage, and liver disease, there are limited data to guide therapy in these conditions.

Intrakranielle Blutung bei erworbener Hemmkörperhämophilie

Acquired hemophilia is a rare complication in autoimmune disorders and malignancies. It can result in bleedings into skin and muscle, whereas intracranial hemorrhage in adults has so far not been described. We report a patient with acute intracerebral hemorrhage due to acquired hemophilia with factor VIII inhibition. The patient was treated with recombinant factor VIIa and open hematoma evacuation followed by administration of cortisone and cyclophosphamide. After good initial recovery, intracerebral rebleeding occurred and the patient died from brainstem compression.