Efficacy and Safety of Recombinant Activated Factor VII Off-label Use in a Pediatric Hematology/Oncology Cohort

Off-label use of recombinant activated factor VII in hemophagocytic lymphohistiocytosis patients with major bleeding

Hemophagocytic lymphohistiocytosis (HLH) is a fatal multi-systemic disorder. Patients with HLH are more prone to bleeding, which implies a poor outcome. The objective was to investigate the efficacy of recombinant activated factor VII (rFVIIa) in major intractable bleeding of HLH. A total of 20 patients with secondary HLH received at least one dose of rFVIIa. When bleeding occurs, 88.9% cases had a nadir platelet counts below 25*109/L. Median number of doses of rFVIIa was 3.5 (range, 1 to 78) with a mean dose of 76.45 µg/kg/dose. Total of 60% (12 of 20) patients obtained a response to rFVIIa therapy, however, in patients with a history of chronic active EBV infection (CAEBV), only 27.3% achieved a response. The mortality rate was 90% (18 of 20) in the cohort, none of the deaths were attributed to rFVIIa administration. Thromboembolism rate was low.

Use of recombinant activated factor VII for uncontrolled bleeding in a haematology/oncology paediatric ICU cohort

: Bleeding among critically ill paediatric haematology/oncology (CIPHO) patients leads to significant morbidity and mortality. Recombinant activated factor VII (rFVIIa) has shown some benefits in previous reported off-label use when conventional therapies have failed. However, data in CIPHO are lacking. We retrospectively studied (2006-2014) the efficacy and outcomes in CIPHO patients younger than 21 years who received at least one rFVIIa dose for bleeding in the ICU. Of 39 patients, the majority had leukaemia (59%), bone marrow transplantation (77%) and a life-threatening bleed (80%) with most common site being pulmonary haemorrhage (44%). Most needed invasive mechanical ventilation (87%) or vasopressor support (59%). After rFVIIa administration, 56% had cessation or decreased bleeding. Packed red blood cell transfusion requirements decreased significantly 48-72 h after rFVIIa administration. Lower baseline prothrombin time and more rFVIIa doses were related to bleeding control. A favourable response was associated with higher survival (55% in responders versus 18% in nonresponders, P = 0.019). Overall, bleeding-related mortality was 37.5%, highest in pulmonary haemorrhage. Two patients had thromboembolic events. Use of rFVIIa for CIPHO patients appears to be well tolerated with low adverse events. Despite half of the patients having a favourable response of cessation or decrease in bleeding after rFVIIa administration, mortality was high. These findings highlight the need for prospective studies to evaluate interventions to improve outcomes in this population.