Efficacy and Safety of Recombinant Activated Factor VII to Control Bleeding in Nonhemophiliac Patients: A Review of 17 Randomized Controlled Trials

Adverse Effects of Perioperative Blood Transfusion in Spine Surgery

BACKGROUND

Perioperative blood transfusion is often necessary during spine surgery because of blood loss from the surgical field during and after surgery. However, blood transfusions are associated with a small but significant risk of causing several adverse events including hemolytic transfusion reactions and transfusion-associated circulatory overload. Moreover, many prior publications have noted increased rates of perioperative morbidity and worsened outcomes in spine surgery patients who received blood transfusions. We performed a systematic review of the literature to better characterize the effects of blood transfusion on spine surgery outcomes.

METHODS

The PubMed/MEDLINE database was queried using the composite key word "transfus∗ AND 'spine surgery.'" A title and abstract review were performed to identify articles for final inclusion.

RESULTS

A title and abstract review of the resulting 372 English-language articles yielded 13 relevant publications, which were subsequently incorporated into this systematic review. All included studies were retrospective, nonrandomized analyses.

CONCLUSIONS

Overall, prior literature indicates a relationship between perioperative blood transfusion and worsened outcomes after spine surgery. However, the available data represent level IV evidence at best. In the future, prospective, randomized, controlled studies may help define the effects of perioperative blood transfusion on spine surgery outcomes.

Use of recombinant activated factor VII for the treatment of perioperative bleeding in noncardiac surgery patients without hemophilia: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the efficacy and safety of perioperative use of recombinant activated factor VII (rFVIIa) in noncardiac patients.

MATERIALS AND METHODS

We searched electronic databases for randomized controlled trials (RCTs) that involved the use of rFVIIa through December 13, 2019 in noncardiac patients without hemophilia. Two investigators extracted the related data and assessed the quality of the included trials.

RESULTS

Eleven RCTs examining 993 perioperative patients were ultimately included. The use of rFVIIa did not decrease all-cause mortality (RR:0.90; 95% CI:0.50,1.64; I² = 0.0%; P = 0.738), shorten the length of ICU (SMD:-0.15; 95% CI:-0.47,0.17; I² = 0.0%; P = 0.346) or hospital (SMD:0.42; 95% CI:-0.05,0.89; I² = 0.0%; P = 0.078) stay, or increase incidence of the thromboembolic events (RR:1.30; 95% CI:0.70,2.41; I² = 0.0%; P = 0.403) among perioperative patients. However, individual RCT analyses showed that the use of rFVIIa could reduce the volume of blood loss (including prostatic cancer, severe acute pancreatitis (SAP), and spinal disease) and the transfusion of RBCs (including prostatic cancer, SAP, and spinal disease) and FFP (SAP) in a subset of perioperative patients. Publication bias was not present.

CONCLUSIONS

For perioperative hemorrhagic patients, rFVIIa-based hemostatic therapy showed no effect on mortality, ICU or hospital LOS, or the rate of thromboembolic events, although it appears to decrease blood loss and reduce the need for blood product transfusion in a subset of patients.

Thrombotic events with recombinant activated factor VII (rFVIIa) in approved indications are rare and associated with older age, cardiovascular disease, and concomitant use of activated prothrombin complex concentrates (aPCC)

Purpose

Recombinant activated factor VII (rFVIIa; NovoSeven^® RT; Novo Nordisk A/S, Bagsvaerd, Denmark) is approved in the United States for the treatment of bleeding and perioperative management in congenital hemophilia with inhibitors (CHwI), acquired hemophilia (AH), congenital factor VII (FVII) deficiency, and Glanzmann’s thrombasthenia (GT) with refractoriness to platelets. The aim of the current analysis was to review clinical trials and registries pre- and post-licensure for each indication to establish the estimated rate of thrombosis and then to establish the association of all reported thrombotic events (TEs) with certain risk factors listed for many years in the prescribing information (PI).

Patients and methods

A retrospective safety assessment of both clinical trials and registries used to support licensure and postmarketing surveillance was performed. The rate of thrombosis was calculated in the 4 indicated disorders and an assessment of TE risk factors was conducted through a review of all narratives within those indications in the safety database.

Results

In clinical trials and registries used to support licensure and in postmarketing surveillance, the overall rate of thrombosis was 0.17% of 12,288 bleeding and surgical episodes. The specific risk by indication was 0.11% for CHwI, 0.82% for FVII deficiency, 0.19% for GT, and 1.77% for AH. The most common associated risk factor—“elderly” (29%), defined in the PI as age ≥65 years—was particularly prevalent in patients with AH. TE was also frequently reported with concomitant cardiac or vascular disease (18%) and use of activated prothrombin complex concentrates (18%).

Conclusion

Data show that the rate of TEs within the 4 licensed indications is low, as was originally described in the US PI from 1999 to 2009. It has remained stable over time during postapproval surveillance in multiple US and global registries with active surveillance for safety information across the 4 approved indications.

Recombinant activated factor VII for uncontrolled bleeding postcardiac surgery

A retrospective observational study to review the safety and efficacy of rFVIIa in persistent hemorrhage in post cardiac surgical patients.

Methods

Patients who had bleeding of 3 ml/kg/h or more for 2 consecutive hours after cardiac surgery were arranged into two groups; control group, who received conventional treatment and rFVIIa group, who received conventional treatment and rFVIIa.

Results

There was no significant difference in demographic and surgical characteristics of both groups. The chest tube output significantly decreased in the rFVIIa group compared to the other group 4 hours after admission {1.4 (IQR: 1–2.2) ml/kg/h vs 3.9 (IQR: 3.1–5.6) ml/kg/h; p = 0.004} and continues to be significant till 9 hours after CSICU admission {0.6 (IQR: 0.4–1.1) ml/kg/h vs 1.9 (IQR: 1.2–2.2) ml/kg/h; p = 0.04}. The median number of blood products units transfused to rFVIIa group was significantly lower compared to control group in the period from 3–12 hours after CSICU admission. 13 (5.5%) patients in rFVIIa group had Thromboembolic adverse events (TAE) compared to 7 (2.4%) patients in other group p = 0.27. 8 patients in the rFVIIa group needed reexploration compared to 19 patients in the other group, p = 0.01. No significant difference was noticed between the 2 groups regarding: new onset renal failure, median number of mechanical ventilator days, pneumonia, mediastinitis, ICU and hospital lengths of stay, survival at 30 days and at discharge.

Conclusion

In this analysis, rFVIIa succefully reduced the chest tube bleeding and blood products transfused during severe post cardiac surgical bleeding. However, safety of rFVIIa remains unclear. Prospective controlled trials are still needed to confirm the role of rFVIIa.

Consensus review of the treatment of cardiovascular disease in people with hemophilia A and B

With advances in care, increasing numbers of people with hemophilia (PWH) achieve near-normal life expectancies and present with typical age-related cardiovascular conditions. Evidence-based guidelines for medical or surgical management of cardiovascular conditions in individuals with hemophilia are limited. Published recommendations exist for the management of some common cardiovascular conditions (eg, ischemic heart disease, atrial fibrillation), but identifying optimal strategies for anticoagulant or antithrombotic therapy constitutes the primary challenge of managing nonoperative cardiovascular disease (CVD) in PWH. In general, as long as factor concentrates or other hemostatic therapies maintain adequate hemostasis, the recommended medical and surgical management of CVD in PWH parallels that in individuals without hemophilia. The presence of factor inhibitors complicates hemophilia management. Published outcomes of CVD treatment in PWH are similar to those in the general population. Specific knowledge about factor replacement, factor inhibitors, and disease-specific treatment distinguishes the cardiovascular care of PWH from similar care of individuals without this rare bleeding disorder. Furthermore, a multidisciplinary approach incorporating a hematologist with an onsite coagulation laboratory, ideally associated with a hemophilia treatment center, is integral to the management of CVD in PWH.

Treatment of diffuse alveolar hemorrhage secondary to lupus erythematosus with recombinant activated factor VII administered with a jet nebulizer

Diffuse alveolar hemorrhage (DAH) is a serious pulmonary complication in patients with autoimmune diseases who are undergoing chemotherapy or have had hematopoietic stem cell transplantation. The use of recombinant factor VIIa (rFVIIa) to treat the acute phase of DAH by endobronchial bronchoscopy has been shown to have a significant clinical impact on the survival and evolution of these patients. We report a clinical case of a patient with DAH secondary to systemic lupus erythematosus (SLE) who was treated with rFVIIa administered using a jet nebulizer, obtaining an adequate hemostatic effect with immediate control of DAH and a significant improvement in gas exchange.

2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines

BACKGROUND

Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007.

METHODS

The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector.

RESULTS

In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management.

CONCLUSIONS

Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.

Off-label use of recombinant factor VIIa in U.S. hospitals: analysis of hospital records

BACKGROUND

Recombinant factor VIIa (rFVIIa) is approved for treatment of bleeding in patients who have hemophilia with inhibitors but has been applied to a wide range of off-label indications.

OBJECTIVE

To estimate patterns of off-label rFVIIa use in U.S. hospitals.

DESIGN

Retrospective database analysis.

SETTING

Data were extracted from the Premier Perspectives database (Premier, Charlotte, North Carolina), which contains discharge records from a sample of academic and nonacademic U.S. hospitals.

PATIENTS

12 644 hospitalizations for patients who received rFVIIa during a hospital stay.

MEASUREMENTS

Hospital diagnoses and patient dispositions from 1 January 2000 to 31 December 2008. Statistical weights for each hospital were used to provide national estimates of rFVIIa use.

RESULTS

From 2000 to 2008, off-label use of rFVIIa in hospitals increased more than 140-fold, such that in 2008, 97% (95% CI, 96% to 98%) of 18 311 in-hospital uses were off-label. In contrast, in-hospital use for hemophilia increased less than 4-fold and accounted for 2.7% (CI, 1.9% to 3.5%) of use in 2008. Adult and pediatric cardiovascular surgery (29% [CI, 21% to 33%]), body and brain trauma (29% [CI, 19% to 38%]), and intracranial hemorrhage (11% [CI, 7.7% to 14%]) were the most common indications for rFVIIa use. Across all indications, in-hospital mortality was 27% (CI, 19% to 34%) and 43% (CI, 26% to 59%) of patients were discharged to home.

LIMITATION

Accuracy and completeness of the discharge diagnoses and patient medication records in the database sample cannot be verified.

CONCLUSION

Off-label use of rFVIIa in the hospital setting far exceeds use for approved indications. These patterns raise concern about the application of rFVIIa to conditions for which strong supporting evidence is lacking.

Trauma-induced coagulopathy--a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice?

Systematic reviews are accepted as a robust and less biased means of appraising and synthesizing results from high-quality studies. This report collated and summarized all the systematic review evidence relating to the diagnosis and management of trauma-related coagulopathy and transfusion, thereby covering the widest possible body of literature. We defined 4 key clinical questions: (1) What are the best methods of predicting and diagnosing trauma-related coagulopathy? (2) Which methods of clinical management correct coagulopathy? (3) Which methods of clinical management correct bleeding? and (4) What are the outcomes of transfusion in trauma? Thirty-seven systematic reviews were identified through searches of MEDLINE (1950-July 2010), EMBASE (1980-July 2010), The Cochrane Library (Issue 7, 2010), National Guidelines Clearing House, National Library for Health Guidelines Finder, and UKBTS SRI Transfusion Evidence Library (www.transfusionevidencelibrary.com). The evidence from the systematic review literature was scanty with many gaps, and we were not able to conclusively answer any of our 4 questions. Much more needs to be understood about how coagulopathy and bleeding in trauma are altered by transfusion practices and, most importantly, whether this translates into improved survival. There is a need for randomized controlled trials to answer these questions. The approach described in this report provides a framework for incorporating new evidence.

Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia

BACKGROUND

Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies. It is also increasingly being used for off-license indications to prevent bleeding in operations where blood loss is likely to be high, and/or to stop bleeding that is proving difficult to control by other means.

OBJECTIVES

To assess the effectiveness of rFVIIa when used therapeutically to control active bleeding, or prophylactically to prevent (excessive) bleeding in patients without haemophilia.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE, EMBASE and other specialised databases up to 25 February 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population (except haemophilia). Outcomes were mortality, blood loss or control of bleeding, red cell transfusion requirements, number of patients transfused and thromboembolic adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed potentially relevant studies for inclusion, extracted data and examined risk of bias. We considered prophylactic and therapeutic rFVIIa studies separately.

MAIN RESULTS

Twenty-five RCTs were included: 24 were placebo-controlled double-blind RCTs and one compared different doses of rFVIIa.Fourteen trials involving 1137 participants examined the prophylactic use of rFVIIa; 713 received rFVIIa. There was no evidence of mortality benefit (RR 1.06; 95% CI 0.50 to 2.24). There was decreased blood loss (WMD -272 mL; 95% CI -399 to -146) and decreased red cell transfusion requirements (WMD -243 mL; 95% CI -393 to -92) with rFVIIa treatment; however these values were likely overestimated due to the inability to incorporate data from trials showing no difference of rFVIIa treatment compared to placebo. There was a trend in favour of rFVIIa in the number of participants transfused (RR 0.91; 95% CI 0.82 to 1.02). But there was a trend against rFVIIa with respect to thromboembolic adverse events (RR 1.32; 95% CI 0.84 to 2.06).Eleven trials involving 2366 participants examined the therapeutic use of rFVIIa; 1507 received rFVIIa. There were no outcomes where any observed advantage, or disadvantage, of rFVIIa over placebo could not have been observed by chance alone. There was a trend in favour of rFVIIa for reducing mortality (RR 0.89; 95% CI 0.77 to 1.03). However, there was a trend against rFVIIa for increased thromboembolic adverse events (RR 1.21; 95% CI 0.93 to 1.58).

AUTHORS' CONCLUSIONS

The effectiveness of rFVIIa as a more general haemostatic drug, either prophylactically or therapeutically, remains unproven. The use of rFVIIa outside its current licensed indications should be restricted to clinical trials.

The contemporary role of blood products and components used in trauma resuscitation

INTRODUCTION

There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation.

METHODS

An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area.

RESULTS

Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy.

CONCLUSION

In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.

Use of recombinant factor VIIa in US military casualties for a five-year period

BACKGROUND

Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes. This study was undertaken to assess how deployed physicians are using rFVIIa and its impact on casualty outcomes.

METHODS

US combat casualties (n = 2,050) receiving any blood transfusion from 2003 to 2009 were reviewed to compare patients receiving rFVIIa (n = 506) with those who did not (n = 1,544). Propensity-score matching (primary analysis) and multivariable logistic regression were used to compare outcomes. Differences were determined at p < 0.05.

RESULTS

Twenty-five percent of patients received rFVIIa. Significant differences were noted between groups in indices of injury severity (Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Scale score), admission physiology (systolic blood pressure, diastolic blood pressure, heart rate, temperature, base deficit, hemoglobin, and international normalization ratio), and use of blood products, indicating that patients treated with rFVIIa were more severely injured, in shock, and coagulopathic. For propensity-score matching, factors associated with death were used: Injury Severity Score, Glasgow Coma Scale score, heart rate, systolic blood pressure, diastolic blood pressure, Hgb, and total packed red blood cell. A total of 266 patients per group were matched; 52% of the rFVIIa group. After pairing, there were no significant differences in any of the demographics, including incidence of massive transfusion (53% vs. 51%). There was no difference in the rate of complications (21% vs. 21%) or mortality (14% vs. 20%) for patients not treated or receiving rFVIIa, respectively.

CONCLUSION

In military casualties, rFVIIa is used in the most severely injured patients based on physician selection rather than on guideline criteria. Use of rFVIIa is not associated with an improvement in survival or an increase in complications. The undetected bias of physician selection of patients for treatment with rFVIIa, likely, has an impact on case matching to achieve equivalence similar to that of randomized control studies. This inability to match populations, thus, prevents definitive interpretation of this study and others studies of similar design. This problem emphasizes the need to develop entry criteria to identify patients who could potentially benefit from use of rFVIIa and the need to subsequently perform efficacy studies.

Use of clotting factors and other prohemostatic drugs for obstetric hemorrhage

PURPOSE OF REVIEW

To guide the optimal use of blood products and to clarify the indications for prohemostatic drugs in obstetric hemorrhage.

RECENT FINDINGS

The literature emphasizes the usefulness of transfusing packed red blood cells, fresh frozen plasma and platelets earlier and in defined ratios to prevent dilutional coagulopathy during obstetric hemorrhage. The value of fibrinogen concentrate and prohemostatic drugs such as tranexamic acid and recombinant factor VIIa is also pointed out.

SUMMARY

It seems reasonable to use blood products for transfusion earlier and in a 1: 1 fresh frozen plasma: red blood cell ratio during acute obstetric hemorrhage; however, this analysis is mainly based on trauma literature. Fibrinogen concentrate should be added if the fibrinogen plasma level remains below 1.0 g l(-1) and perhaps even as soon as it falls below 1.5-2.0 g l(-1); the addition of tranexamic acid (1 g) is cheap, likely to be useful and appears safe. Data on the proactive administration of platelets are insufficient to recommend this practice routinely. Presently, recombinant factor VIIa (60-90 microg kg(-1)) is advocated only after failure of other conventional therapies, including embolization or conservative surgery, but prior to obstetric hysterectomy. Prospective randomized controlled trials are highly desirable.

Recombinant activated factor VII attenuates major arterial bleeding in noncoagulopathic rabbits

BACKGROUND AND OBJECTIVE

Recombinant activated factor VII (rFVIIa), which is used off-label as an adjuvant therapy for uncontrolled and life-threatening bleeding, might also attenuate intractable bleeding related to macrovascular arterial lesions. Here we evaluated the efficacy of rFVIIa in sealing a large arterial wound in haemostatically competent rabbits.

METHODS

Sixty male New Zealand rabbits were randomly divided into vehicle control and 80 and 200 μg kg⁻¹ rFVIIa groups (n = 20 animals each). A standardized wound of the isolated right carotid artery was made in all rabbits with an 18-G catheter. Bleeding, which was limited by mild compression, was assessed every minute. At 5 min, an intravenous bolus of vehicle or human rFVIIa was given and the animals were further observed for 1 h. Efficacy was assessed from the bleeding duration and blood mass lost. Statistical significance was defined as P less than 0.05. All investigators were blinded to the treatment the animals received.

RESULTS

The bleeding duration and blood mass lost were significantly reduced in both rFVIIa dosage groups as compared with the vehicle control group. For the vehicle, 80 and 200 μg kg⁻¹ rFVIIa groups, the median bleeding durations were 56 min (range 7-60 min), 15 min (range 5-60 min) and 10 min (range 5-60 min), respectively; and the median blood mass losses were 22.5 g (range 1-58 g), 12 g (range 0-36 g) and 5 g (range 0-31 g), respectively. The prothrombin time was shorter in the rFVIIa groups. Visual inspection of the carotid artery and microscopic analysis of the liver and kidney revealed neither gross thrombi nor entrapped microthrombi in any rabbit.

CONCLUSION

Recombinant FVIIa at 80 or 200 μg kg⁻¹ promoted the sealing of a large and slightly compressed arterial wound in rabbits. These results suggest a potential role for the drug in the management of massive bleeds due to an arterial lesion when surgical intervention is not immediately and readily available. Safety should remain a matter of concern.

Correction of coagulation in dilutional coagulopathy: use of kinetic and capacitive coagulation assays to improve hemostasis

The management of dilutional coagulopathy due to fluid infusion and massive blood loss is a topic that deserves a biochemical approach. In this review article, we provide an overview of current guidelines and recommendations on diagnosis and on management of transfusion in acquired coagulopathy. We discuss the biochemical differences between kinetic clotting assays (clotting times) and new capacitive coagulation measurements that provide time-dependent information on thrombin generation and fibrin clot formation. The available evidence suggests that a combination of assay types is required for evaluating new transfusion protocols aimed to optimize hemostasis and stop bleeding. Although there is current consensus on the application of fresh frozen plasma to revert coagulopathy, factor concentrates may appear to be useful in the future.

Managing fibrinolysis without aprotinin

Cardiopulmonary bypass increases perioperative bleeding and produces a consumptive coagulopathy, which is defined as the simultaneous production of thrombin and fibrinolysis. Thrombin formation and fibrinolysis primarily occur in the surgical wound and peak at the time heparin is reversed by protamine. Neither aprotinin nor lysine analogs successfully control bleeding in many complex procedures, reoperations, aortic resections, or in implantations of mechanical circulatory devices. This analysis reviews the mechanisms involved and current treatment protocols, with the conclusion that changes in treatment protocols rather than use of a specific anti-fibrinolytic drug may provide better control of bleeding in these patients.

Thromboembolic events with recombinant activated factor VII in spontaneous intracerebral hemorrhage: results from the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial

BACKGROUND AND PURPOSE

Patients with intracerebral hemorrhage have a high risk of thromboembolic events (TEs) due to advanced age, hypertension, atherosclerosis, diabetes, and immobility. Use of recombinant activated factor VII (rFVIIa) could increase TEs in high-risk patients. Factor Seven for Acute Hemorrhagic Stroke (FAST) trial data were reviewed to define the frequency of and risk factors for TE with rFVIIa.

METHODS

Eight hundred forty-one patients presenting <3 hours after spontaneous intracerebral hemorrhage were randomized to 20 or 80 microg/kg of rFVIIa or placebo. Those with Glasgow Coma Scale score <5, planned early surgery, coagulopathy, or recent TE were excluded. Myocardial, cerebral, or venous TEs were subject to detailed reporting and expedited local review. Additionally, a blinded Data Monitoring Committee reviewed all electrocardiograms, centrally analyzed troponin I values, and CT scans.

RESULTS

There were 178 arterial and 47 venous TEs. Venous events were similar across groups. There were 49 (27%) arterial events in the placebo group, 47 (26%) in the 20-microg/kg group, and 82 (46%) in the 80 microg/kg group (P=0.04). Of the myocardial events, 38 were investigator-reported and 103 identified by the Data Monitoring Committee. They occurred in 17 (6.3%) placebo and 57 (9.9%) rFVIIa patients (P=0.09). Arterial TEs were associated with: receiving 80 microg/kg rFVIIa (OR=2.14; P=0.031), signs of cardiac or cerebral ischemia at presentation (OR=4.19; P=0.010), age (OR=1.14/5 years; P=0.0123), and prior use of antiplatelet agents (OR=1.83; P=0.035). Ischemic strokes possibly related to study drug occurred in 7, 5, and 8 patients in the placebo, 20 microg/kg, and 80-microg/kg groups, respectively.

CONCLUSIONS

Higher doses of rFVIIa in a high-risk population are associated with a small increased risk of what are usually minor cardiac events. Demonstration of the ability of rFVIIa to improve outcome in future studies should be driven by its effectiveness in slowing bleeding outweighting the risk of a small increase in arterial TEs.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.

Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia

BACKGROUND

Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies. It is also increasingly being used for off-license indications to prevent bleeding in operations where blood loss is likely to be high, and/or to stop bleeding that is proving difficult to control by other means.

OBJECTIVES

To assess the effectiveness of rFVIIa when used therapeutically to control active bleeding, or prophylactically to prevent (excessive) bleeding in patients without haemophilia.

SEARCH STRATEGY

We searched the Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE, EMBASE and other specialised databases up to March 2006. We also searched reference lists of articles and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population with the exception of those with haemophilia. There was no restriction by outcomes examined, but this review focuses on mortality, blood loss or control of bleeding, red cell transfusion requirements, number of patients transfused and thromboembolic adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed potentially relevant studies for inclusion. Data were extracted and methodological quality was examined. Studies using rFVIIa prophylactically and those using rFVIIa therapeutically have been considered separately. Data were pooled using fixed and random effects models, but random effects models were preferred because of the variability in clinical features of the included studies.

MAIN RESULTS

Thirteen trials met the inclusion criteria; all were placebo-controlled double-blind RCTs. Six trials involving 724 participants examined the prophylactic use of rFVIIa; 379 received rFVIIa. There were no outcomes by which any observed advantage, or disadvantage, of rFVIIa over placebo could not have been observed by chance alone. There were trends in favour of rFVIIa for a number of outcomes, particularly the number of participants transfused, pooled RR 0.85 (95% CI 0.72 to 1.01) but this was balanced by a trend against rFVIIa with respect to thromboembolic adverse events, pooled RR 1.25 (95% CI 0.76 to 2.07). Seven trials involving 1214 participants examined the therapeutic use of rFVIIa; 687 received rFVIIa. There were no outcomes where any observed advantage, or disadvantage, of rFVIIa over placebo could not have been observed by chance alone. There was a trend in favour of rFVIIa for reducing mortality, RR 0.82 (95% CI 0.64 to 1.04), although no other clear trends in favour of rFVIIa were noted for other desired outcomes. Interpretation of these results must take into account one study which could not be included in the quantitative summary but which showed results strongly in favour of rFVIIa for the treatment of intra-cerebral haemorrhage. There was a trend against rFVIIa with respect to thromboembolic adverse events; the RR 1.50 (95% CI 0.86 to 2.62).

AUTHORS' CONCLUSIONS

Although rFVIIa has a role in the management of patients with haemophilia, its effectiveness as a more general haemostatic drug, either prophylactically or therapeutically, remains uncertain. Its effectiveness as a therapeutic agent, particularly for intra-cerebral haemorrhage, looks more encouraging than prophylactic use. The use of rFVIIa outside its current licensed indications should be very limited and its wider use await the results of ongoing and possibly newly commissioned RCTs. In the interim, rFVIIa use should be restricted to clinical trials.