Epsilon-aminocaproic acid inhibits the activity of factor VIII inhibitors in patients with severe haemophilia A in vivo and in vitro

Hemostasis research in India: past, present, and future

Hemostasis research in India has a long history considering the fact that it is one of the youngest specialities in the world. If we take creation of prothrombin time (PT) test as one of the beginning of modern hemostsis research, then the specialty is no older than 60 years. School of Tropical Medicine Kolkata, Banaras Hindu University, All India Institute of Medical Sciences at Delhi, Christian Medical College at Vellore, Post Graduate Institute of Medical Education and Research at Chandigarh, and KEM Hospital at Mumbai contributed substantially in defining various bleeding disorders in our country. Unfortunately, some of these institutes are no longer as active in the field as they used to be. Currently, the Institute of Immunohaematology at Mumbai, Chrstian medical College at Vellore, and All India Institute of Medical Sciences at Delhi are actively engaged in hemostsis research in India. Developing prenatal diagnostic technologies, mutation detection of various hemostatic disorders, developing low-cost management technologies for hemophilia, and other bleeding disorders are becoming important present day research activity in the area of hemostasis in addition to age old areas of prevalence and unusual case description studies. Entry of many new corporate hospitals, development of structured postgraduate training program in hematology, and easy availability of instruments and reagents are likely to foster further growth in this area of medical research in India in future.

Haematology research in India: past, present and future

Haematology research in India is relatively recent in origin. However the pioneers in the field not only did exemplary work when compared to advanced western countries, they also made it a point to develop centres of excellence and human resources for future of haematology work in this country. In this brief overview an effort has been made to give a taste of quality and expanse of haematology research in this country. This review does not claim to have described every bit of haematology research in this country. Our pioneers worked under extremely difficult and trying circumstances on a subject which was limited to funding available from Indian Council of Medical Research. Now the times have changed, several funding agencies in the country are able to provide substantial fund for research. Modern state of the art basic research institutions are tying up with medical colleges for good quality research and the seeds which our pioneers had planted have grown into a mighty tree. It would not be an exaggeration to say we are on the threshold of the golden era of haematology research in this country.

Management of haemophilia and its complications in developing countries

Eighty per cent of people with haemophilia live in developing countries, where technical expertise and health care facilities may be less than optimal. Haemophilia is a relatively rare disease and high-cost, technology-intensive therapy is not a high priority for the governments of developing countries. The rapid spread of transfusion-related viral infections in many developing countries presents further problems for haemophiliacs. However, it is possible to manage haemophiliacs patients with limited resources. Strategies for conserving factor concentrates, include education of doctors and patients, prenatal diagnosis, increasing the use of anti-fibrinolytic agents, physiotherapy, the use of fibrin glue, and simple orthotics and prosthetic measures. These approaches are helpful in the majority of these patients. Meanwhile, with the help of the World Federation of Haemophilia (WFH), all developing countries are gradually improving management skills for this relatively rare but disabling disease. The present review broadly describes the management of various aspects of severe haemophilia in developing countries.

Role of epsilon amino caproic acid in the management of haemophilic patients with inhibitors

We managed bleeding crisis in 10 consecutive severe haemophilic patients with inhibitors (eight had an inhibitor level of >5 BU mL(-1)) mainly with the antifibrinolytic agent, i.e. epsilon amino caproic acid (EACA). EACA was used by local, oral or intravenous routes either in combination or separately. Five patients developed inhibitors postoperatively and among the remaining five, four had recurrent haemarthrosis or soft tissue bleeds and one patient presented with severe gastrointestinal bleeding without demonstrable lesion. In all the patients, addition of EACA to their management protocol resulted in stoppage and/or reduced frequency of bleeding. In six of 10 patients, the results were excellent; of these six patients, five developed inhibitors postoperatively. Although a reduction in the frequency of bleeding was observed in patients with haemarthrosis and soft tissue bleed, it was not spectacular and the patients required additional therapy. Hence the results could be described as poor. No patient needed to stop the medicine because of the side-effect of EACA. Symptoms like mild nausea and vertigo were seen as the side-effects of this medicine when high intravenous dosage was administered. EACA thus appears to be an excellent adjuvant therapy for haemophilic patients with inhibitors. Besides its well-recognized antifibrinolytic activity, EACA may have additional mechanisms of action in haemophilic patients with inhibitors. More extensive use of this cheap and safe product is warranted in haemophilic patients with inhibitors. If larger studies confirm this observation, then using antifibrinolytics will allow substantial reduction of FEIBA or activated prothrombin complex (APCC) usage in such patients without necessarily increasing the thrombotic complications or reduction of the clinical efficacy, when compared with higher dosage of FEIBA or APCC alone. This will lead to substantial financial savings in countries where up to 35% of severe haemophilia A patients develop inhibitors.

First-time development of FVIII inhibitor in haemophilia patients during the postoperative period

Development of inhibitor to FVIII in haemophilia patients is well-known and is not uncommon. However, their development for the first time during the postoperative period has hardly been reported. In a developing country such as India, where resources are limited, development of such an eventuality may prove disastrous. However, as many of our patients are sparingly treated, therefore, even if they test negative for the inhibitor preoperatively, they may get the requisite FVIII antigenic stimulation during the preoperative and immediate postoperative period, leading to the development of inhibitors during this critical time of wound healing. We describe here six patients who developed such an inhibitor, from a group of 35 patients with haemophilia A who underwent various surgical procedures (19%). We stress that such an eventuality may not remain rare in developing countries as more patients of severe haemophilia undergo surgery and are therefore challenged for the first time in their life with large amounts of FVIII concentrate during their preoperative period.