A controlled trial of tranexamic acid therapy for the reduction of bleeding during treatment of acute myeloid leukemia

Prophylaxis with low dose tranexamic acid in acute myeloid leukemia patients undergoing intensive chemotherapy

Patients suffering from acute myeloid leukemia (AML) carry a high risk of serious bleeding complications due to severe thrombocytopenia for long periods of time during treatment. Prior to prophylactic platelet transfusion becoming the standard of care, intracranial bleeding was a major contributor to death in AML patients. However, despite prophylactic platelet transfusions, up to 79% of patients with AML experience clinically significant bleeding during treatment. Antifibrinolytics are effective and well tolerated hemostatic agents widely used in many patient groups, and in this study, we investigated the effect of low dose tranexamic acid (TXA) in patients with AML and thrombocytopenia. We compared bleeding and thrombosis between 113 thrombocytopenic AML patients receiving TXA 500 mg three times daily (n = 36) versus no-TXA (n = 77). Clinical information was obtained systematically from electronic medical records, and laboratory data were collected from the laboratory information system. No difference was demonstrated in number of patients with at least one bleeding episode (TXA: 89% vs. no-TXA: 93%, p = 0.60), median number of bleeding days (TXA: 2.5 days vs. no-TXA 2.0 days, p = 0.30), bleeding location or transfusion needs between the two groups. However, platelet count was found to be a significant risk factor for bleeding, with a probability of bleeding of 35% with a platelet count below 5 × 109/L (logistic regression, p < 0.01). We found no difference in thromboembolic events between the two groups (TXA: 8% vs. no-TXA 10%, p = 0.99). In conclusion, treatment with low dose TXA is safe, but we found no evidence to suggest that it reduces bleeding in AML patients with thrombocytopenia.

Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Implementation Protocol Results and Trial Prospectus

OBJECTIVE

Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability-potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion.

METHODS

Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA.

RESULTS

Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding.

CONCLUSIONS

Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously.

Tranexamic acid evidence and controversies: An illustrated review

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA persists in many clinical settings. This illustrated review describes the history, pharmacology, and practical considerations of TXA use. We also describe the major landmark randomized controlled trials of TXA and their implications. Finally, we review the evidence around common controversies surrounding TXA such as the risk of thrombosis, prescription along with combined hormonal contraceptives, and use in patients with gross hematuria.

Challenges and Advances in Managing Thrombocytopenic Cancer Patients

Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.

How well do platelets prevent bleeding?

Prophylactic platelet transfusions are used to reduce the risk of spontaneous bleeding in patients with treatment- or disease-related severe thrombocytopenia. A prophylactic platelet-transfusion threshold of <10 × 103/µL has been shown to be safe in stable hematology/oncology patients. A higher threshold and/or larger or more frequent platelet doses may be appropriate for patients with clinical features associated with an increased risk of bleeding such as high fevers, sepsis, disseminated intravascular coagulation, anticoagulation therapy, or splenomegaly. Unique factors in the outpatient setting may support the use of a higher platelet-transfusion threshold and/or dose of platelets. A prophylactic platelet-transfusion strategy has been shown to be associated with a lower risk of bleeding compared with no prophylaxis in adult patients receiving chemotherapy but not for autologous transplant recipients. Despite the use of prophylactic platelet transfusions, a high incidence (50% to 70%) of spontaneous bleeding remains. Using a higher threshold or larger doses of platelets does not change this risk. New approaches to reduce the risk of spontaneous bleeding, including antifibrinolytic therapy, are currently under study.

Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH

Patients with acute leukemia frequently develop thrombocytopenia and hemostatic complications caused by coagulopathy. Coagulopathy complicates the management of these patients and can lead to significant morbidity and mortality. This guidance document aims to review and provide guidance on the management of hemostatic complications in adult patients with acute leukemia, addressing four main issues, including platelet transfusion, disseminated intravascular coagulation, L-asparaginase-related hypofibrinogenemia, and the use of antifibrinolytic agents.

The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients

Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.

The TREATT Trial (TRial to EvaluAte Tranexamic acid therapy in Thrombocytopenia): safety and efficacy of tranexamic acid in patients with haematological malignancies with severe thrombocytopenia: study protocol for a double-blind randomised controlled trial

Background

Patients with haematological malignancies often develop thrombocytopenia as a consequence of either their disease or its treatment. Platelet transfusions are commonly given to raise a low platelet count and reduce the risk of clinical bleeding (prophylaxis) or stop active bleeding (therapy). Recent studies have shown that many patients continue to experience bleeding despite the use of prophylactic platelet transfusions. Tranexamic acid is an anti-fibrinolytic, which reduces the breakdown of clots formed in response to bleeding. Anti-fibrinolytics have been shown to prevent bleeding, decrease blood loss and use of red cell transfusions in elective and emergency surgery, and are used widely in these settings. The aim of this trial is to test whether giving tranexamic acid to patients receiving treatment for haematological malignancies reduces the risk of bleeding or death and the need for platelet transfusions.

Methods

This is a multinational randomised, double-blind, placebo-controlled, parallel, superiority trial. Patients will be randomly assigned to receive tranexamic acid (given intravenously or orally) or a matching placebo in a 1:1 ratio, stratified by site. Patients with haematological malignancies receiving intensive chemotherapy or stem cell transplantation (or both) who are at least 18 years of age and expected to become severely thrombocytopenic for at least 5 days will be eligible for this trial. The primary outcome of the trial is the proportion of patients who died or had bleeding of World Health Organization grade 2 or above during the first 30 days of the trial. We will measure the rates of bleeding daily by using a short, structured assessment of bleeding, and we will record the number of transfusions given to patients. We will assess the risk of arterial and venous thrombosis for 120 days from the start of trial treatment.

Discussion

This trial will assess the safety and efficacy of using prophylactic tranexamic acid during a period of intensive chemotherapy and associated thrombocytopenia in people with haematological disorders.

Trial registration

This study was prospectively registered on Current Controlled Trials on 25 March 2015 (ISRCTN73545489) and is also registered on ClinicalTrials.gov (NCT03136445).

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3663-2) contains supplementary material, which is available to authorized users.

Hypoplastic thrombocytopenia and platelet transfusion: therapeutic goals

Platelet transfusions consist a major part of the management of hypoplastic thrombocytopenia, the latter occurring mainly among patients with hematological malignancies. Platelet transfusions have led to a reduction of deaths attributable to thrombocytopenia-induced bleeding, despite their possible complications; nonetheless, prophylactic administration of platelets to patients with severe thrombocytopenia or before invasive procedures should be based on specific criteria, as well as therapeutic administration during active bleeding. Recently developed ex-vivo procedures have resulted in producing safer blood products, yet it remains unclear whether these pathogen-inactivated products have sufficient efficacy. What is more, another significant problem that remains to be more effectively addressed is the developing refractoriness to platelet transfusions.

Effects of Topical Antifibrinolytics in Endoscopic Sinus Surgery: A Pilot Randomized Controlled Trial

Background

Bleeding in endoscopic sinus surgery (ESS) may increase the risk of intraoperative complications and is associated with poorer outcomes Antifibrinolytic agents have been shown to reduce bleeding if administered systemically. The aim of this study was to determine the effect of topical epsilon-aminocaproic acid (EACA) and tranexamic acid (TA) on bleeding in the surgical field during ESS.

Methods

A prospective blind randomized controlled trial was performed. Thirty patients undergoing ESS were randomized to receive either 2.5 g of EACA, 100 mg of TA, or 1 g of TA while the contralateral side received saline. The solution was applied as a spray at the conclusion of operating on each side. Bleeding was documented using standardized videoendoscopy and grading scales.

Results

EACA did not show a significant effect on intraoperative bleeding. TA at 100 mg showed a clinically significant improvement in the surgical field at 2, 4, and 6 minutes after application. The mean for 2 minutes was TA, 1.6 ± 1.08, and control, 2.2 ± 1.3; at 4 minutes was TA, 1.25 ± 1.2, and control, 1.7 ± 1.2,; and at 6 minutes was TA, 0.75 ± 1.2, and control, 1.3 ± 1.4 (p < 0.05). TA at 1 g also approached significance at all time points. Combined results from the two TA groups showed a significant improvement in the surgical field at 2, 4, 6, and 8 minutes after application. TA was regarded by the blinded surgeon as more effective than saline in 80% of cases. No adverse effects were encountered after topical application of either drug.

Conclusion

Topical application of TA is effective in achieving hemostasis and improving the surgical field. In contrast to EACA, TA is a valuable tool in ESS that merits additional evaluation.

Rationale and design of platelet transfusions in haematopoietic stem cell transplantation: the PATH pilot study

INTRODUCTION

In patients with transient thrombocytopenia being treated with high-dose chemotherapy followed by stem cell rescue-haematopoietic stem cell transplantation (HSCT), prophylactic transfusions are standard therapy to prevent bleeding. However, a recent multicentre trial suggests that prophylactic platelet transfusions in HSCT may not be necessary. Additionally, the potential overuse of platelet products places a burden on a scarce healthcare resource. Moreover, the benefit of prophylactic platelet transfusions to prevent clinically relevant haemorrhage is debatable. Current randomised data compare different thresholds for administering prophylactic platelets or prophylactic versus therapeutic platelet transfusions. An alternative strategy involves prescribing prophylactic antifibrinolytic agents such as tranexamic acid to prevent bleeding.

METHODS AND ANALYSIS

This report describes the design of an open-labelled randomised pilot study comparing the prophylactic use of oral tranexamic acid with platelet transfusions in the setting of autologous HSCT. In 3-5 centres, 100 patients undergoing autologous HSCT will be randomly assigned to either a prophylactic tranexamic acid or prophylactic platelets bleeding prevention strategy-based daily platelet values up to 30 days post-transplant. The study will be stratified by centre and type of transplant. The primary goal is to demonstrate study feasibility while collecting clinical outcomes on (1) WHO and Bleeding Severity Measurement Scale (BSMS), (2) transplant-related mortality, (3) quality of life, (4) length of hospital stay, (5) intensive care unit admission rates, (6) Bearman toxicity scores, (7) incidence of infections, (8) transfusion requirements, (9) adverse reactions and (10) economic analyses.

ETHICS AND DISSEMINATION

This study is funded by a peer-reviewed grant from the Canadian Institutes of Health Research (201 503) and is registered on Clinicaltrials.gov NCT02650791. It has been approved by the Ottawa Health Science Network Research Ethics Board. Study results will presented at national and international conferences. Importantly, the results of this trial will inform the feasibility and conduct of a larger study.

TRIAL REGISTRATION NUMBER

NCT02650791; Pre-results.

Antifibrinolytics (lysine analogues) for the prevention of bleeding in people with haematological disorders

BACKGROUND

People with haematological disorders are frequently at risk of severe or life-threatening bleeding as a result of thrombocytopenia (reduced platelet count). This is despite the routine use of prophylactic platelet transfusions to prevent bleeding once the platelet count falls below a certain threshold. Platelet transfusions are not without risk and adverse events may be life-threatening. A possible adjunct to prophylactic platelet transfusions is the use of antifibrinolytics, specifically the lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA). This is an update of a Cochrane review first published in 2013.

OBJECTIVES

To determine the efficacy and safety of antifibrinolytics (lysine analogues) in preventing bleeding in people with haematological disorders.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (The Cochrane Library 2016, Issue 3), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 07 March 2016.

SELECTION CRITERIA

We included RCTs involving participants with haematological disorders, who would routinely require prophylactic platelet transfusions to prevent bleeding. We only included trials involving the use of the lysine analogues TXA and EACA.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all electronically-derived citations and abstracts of papers, identified by the review search strategy, for relevancy. Two review authors independently assessed the full text of all potentially relevant trials for eligibility, completed the data extraction and assessed the studies for risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. We requested missing data from one author but the data were no longer available. The outcomes are reported narratively: we performed no meta-analyses because of the heterogeneity of the available data.

MAIN RESULTS

We identified three new studies in this update of the review. In total seven studies were eligible for inclusion, three were ongoing RCTs and four were completed studies. The four completed studies were included in the original review and the three ongoing studies were included in this update. We did not identify any RCTs that compared TXA with EACA.Of the four completed studies, one cross-over TXA study (eight participants) was excluded from the outcome analysis because it had very flawed study methodology. Data from the other three studies were all at unclear risk of bias due to lack of reporting of study methodology.Three studies (two TXA (12 to 56 participants), one EACA (18 participants) reported in four articles (published 1983 to 1995) were included in the narrative review. All three studies compared the drug with placebo. All three studies included adults with acute leukaemia receiving chemotherapy. One study (12 participants) only included participants with acute promyelocytic leukaemia. None of the studies included children. One of the three studies reported funding sources and this study was funded by a charity.We are uncertain whether antifibrinolytics reduce the risk of bleeding (three studies; 86 participants; very low-quality evidence). Only one study reported the number of bleeding events per participant and there was no difference in the number of bleeding events seen during induction or consolidation chemotherapy between TXA and placebo (induction; 38 participants; mean difference (MD) 1.70 bleeding events, 95% confidence interval (CI) -0.37 to 3.77: consolidation; 18 participants; MD -1.50 bleeding events, 95% CI -3.25 to 0.25; very low-quality evidence). The two other studies suggested bleeding was reduced in the antifibrinolytic study arm, but this was statistically significant in only one of these two studies.Two studies reported thromboembolism and no events occurred (68 participants, very low-quality evidence).All three studies reported a reduction in platelet transfusion usage (three studies, 86 participants; very low-quality evidence), but this was reported in different ways and no meta-analysis could be performed. No trials reported the number of platelet transfusions per participant. Only one study reported the number of platelet components per participant and there was a reduction in the number of platelet components per participant during consolidation chemotherapy but not during induction chemotherapy (consolidation; 18 participants; MD -5.60 platelet units, 95% CI -9.02 to -2.18: induction; 38 participants, MD -1.00 platelet units, 95% CI -9.11 to 7.11; very low-quality evidence).Only one study reported adverse events of TXA as an outcome measure and none occurred. One study stated side effects of EACA were minimal but no further information was provided (two studies, 74 participants, very low-quality evidence).None of the studies reported on the following pre-specified outcomes: overall mortality, adverse events of transfusion, disseminated intravascular coagulation (DIC) or quality of life (QoL).

AUTHORS' CONCLUSIONS

Our results indicate that the evidence available for the use of antifibrinolytics in haematology patients is very limited. The trials were too small to assess whether or not antifibrinolytics decrease bleeding. No trials reported the number of platelet transfusions per participant. The trials were too small to assess whether or not antifibrinolytics increased the risk of thromboembolic events or other adverse events. There are three ongoing RCTs (1276 participants) due to be completed in 2017 and 2020.

Treatment for disseminated intravascular coagulation in patients with acute and chronic leukemia

BACKGROUND

Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, leading to deposition of fibrin in the bloodstream. It may occur in patients with acute and chronic leukemia and is particularly associated with acute promyelocytic leukemia (a subtype of acute myeloid leukemia).

OBJECTIVES

To assess the clinical benefits and harms of any pharmacological intervention for treating DIC in patients with acute or chronic leukemia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 05), MEDLINE (1946 to 7 May 2015), LILACS (1982 to 7 May 2015) and African Index Medicus (7 May 2015). There was no language restrictions. We sought additional randomized controlled trials (RCTs) from the World Health Organization International Clinical Trials Registry Platform and the reference lists of primary studies identified.

SELECTION CRITERIA

RCTs assessing the clinical benefits and harms of interventions for treating DIC in patients with acute and chronic leukemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed trial selection, 'Risk of bias' assessment and data extraction. Primary outcomes were overall mortality, in-hospital mortality from any cause (15-day and 30-day) and adverse events.

MAIN RESULTS

In this Cochrane Review update we did not include any new RCT compared with the first review version. Accordingly, four RCTs (388 participants) met the inclusion criteria. These trials evaluated the human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate. Included trials reported data on mortality and bleeding. The studies were conducted in Japan, Italy and the Netherlands. We classified the included trials as: 1) including patients with or without leukemia which did not report data for the leukemia subgroup (366 participants); and 2) only including patients with leukemia (22 participants). Overall, the risk of bias of the included trials was high, since the trial authors did not provide a detailed description about trial design and execution.According to the GRADE recommendations, we judged the overall quality of the body of evidence for all prefixed outcomes as 'very low', due to methodological limitations and very small sample size.One trial, including 10 participants with leukemia and comparing dermatan sulphate with heparin, reported no deaths during trial treatment.In terms of bleeding data, we were unable to pool results from two studies that were only conducted with leukemia patients due to the inconsistency in the measurement and reporting of this outcome. One trial, including 12 participants with leukemia, found very low quality evidence that tranexamic acid can reduce the cumulative hemorrhagic score in participants compared with those assigned to placebo (P = 0.0015, very low quality evidence). On the contrary, there is no evidence that dermatan sulphate compared with placebo reduces new events of hemorrhagic diathesis (1/5 (20%) versus 2/5 (40%); RR 0.50; 95% CI 0.06 to 3.91; P = 0.51, very low quality evidence).No thromboembolic complications were reported in either trial that included patients with leukemia only (very low quality evidence). The safety profile was inconclusive.The included trials did not assess overall mortality, resolution of respiratory failure, renal failure or shock.

AUTHORS' CONCLUSIONS

Due to a lack of new RCTs, our conclusions in this Cochrane Review update are the same as the previous review version. We included four RCTs which reported mortality and bleeding data. It is not possible to determine whether human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate are effective or harmful for patients presenting with DIC related to acute or chronic leukemia. The quality of the evidence was low to very low. Therefore, prescription of these interventions for treating DIC in patients with acute and chronic leukemia can neither be supported nor rejected, unless new evidence from a large high-quality trial alters this conclusion.

Thrombocytopenia in cancer patients

Thrombocytopenia is a frequent complication of cancer and its treatment. The causes of thrombocytopenia in cancer patients can be diverse and multifactorial. Systemic chemotherapy is the most frequent cause of thrombocytopenia. The degree and duration thrombocytopenia depends upon whether the chemotherapeutic treatment is myeloablative, as used in stem cell transplants, or non-myeloablative, as typically used in solid non-hematologic malignancies. Additional causes of significant thrombocytopenia include tumor involvement of bone marrow and spleen; microangiopathic disorders such as disseminated intravascular coagulation, thrombotic thrombocytopenic purpura or hemolytic uremia syndrome. Lymphoproliferative malignancies can also be associated with secondary immune thrombocytopenia. Due to the broad differential diagnosis associated with cancer related thrombocytopenia, a careful diagnostic evaluation is indicated. The goal of treatment should be to maintain a safe platelet count to allow effective treatment of the underlying malignancy, prevent bleeding complications and to minimize the use of platelet product transfusion.

Aminocaproic acid use in hospitalized patients with hematological malignancy: a case series

The antifibrinolytic aminocaproic acid is widely used in surgical settings to prevent blood loss and decrease transfusion requirements, and small observational studies have suggested that aminocaproic acid may be useful in the setting of malignancy-related bleeding. At our institution, aminocaproic acid is sometimes prescribed to patients with hematological malignancy who experience refractory thrombocytopenia with or without bleeding. We performed a 5-year retrospective review of 54 adult patients with 13 types of hematological malignancy who received aminocaproic acid at our institution. Indications for use included 31 (57.4%) for refractory thrombocytopenia with bleeding, 16 (29.6%) for refractory thrombocytopenia without bleeding, and 7 (13%) for bleeding alone. Patients received both oral and intravenous formulations. Administered doses ranged broadly and median duration of use was 6 days. Three patients (5.7%) developed deep venous thrombosis but none of the thrombotic events were clearly related to administration of aminocaproic acid. We conclude that aminocaproic acid may be a relatively safe and cost-effective adjunct treatment in the setting of bleeding related to the diagnosis and treatment of hematological malignancy. Prospective trials as well as formalized protocols for the use of aminocaproic acid may be indicated. Copyright © 2015 John Wiley & Sons, Ltd.

Antifibrinolytics (lysine analogues) for the prevention of bleeding in patients with haematological disorders

BACKGROUND

Patients with haematological disorders are frequently at risk of severe or life-threatening bleeding as a result of thrombocytopenia. This is despite the routine use of prophylactic platelet transfusions (PlTx) to prevent bleeding once the platelet count falls below a certain threshold. PlTx are not without risk and adverse events may be life-threatening. A possible adjunct to prophylactic PlTxs is the use of antifibrinolytics, specifically the lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA).

OBJECTIVES

To determine the efficacy and safety of antifibrinolytics (lysine analogues) in preventing bleeding in patients with haematological disorders.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL Issue 12, 2012), MEDLINE (1948 to 10 January 2013), EMBASE (1980 to 10 January 2013), CINAHL (1982 to 10 January 2013), PubMed (e-publications only) and the Transfusion Evidence Library (1980 to January 2013). We also searched several international and ongoing trial databases to 10 January 2013 and citation-tracked relevant reference lists.

SELECTION CRITERIA

RCTs involving patients with haematological disorders, who would routinely require prophylactic platelet transfusions to prevent bleeding. We only included trials involving the use of the lysine analogues TXA and EACA.

DATA COLLECTION AND ANALYSIS

Two authors independently screened all electronically derived citations and abstracts of papers, identified by the review search strategy, for relevancy. Two authors independently assessed the full text of all potentially relevant trials for eligibility, completed the data extraction and assessed the studies for risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. We requested missing data from one author but the data were no longer available. The outcomes are reported narratively: we performed no meta-analyses because of the heterogeneity of the available data.

MAIN RESULTS

Of 470 articles initially identified, 436 were excluded on the basis of the title and abstract. We reviewed 34 full-text articles from which four studies reported in five articles were eligible for inclusion. We did not identify any RCTs which compared TXA with EACA. We did not identify any ongoing RCTs.One cross-over TXA study (eight patients) was excluded from the outcome analysis because data from this study were at a high risk of bias. Data from the other three studies were all at unclear risk of bias due to lack of reporting of study methodology.Three studies (two TXA (12 to 56 patients), one EACA (18 patients)) reported in four articles (published 1983 to 1995) were included in the narrative review. All three studies compared the drug with placebo.All studies reported bleeding, but it was reported in different ways. All three studies suggested antifibrinolytics reduced the risk of bleeding. The first study showed a difference in average bleeding score of 42 in placebo (P) versus three (TXA). The second study only showed a difference in bleeding episodes during consolidation chemotherapy, with a mean of 2.6 episodes/patient (standard deviation (SD) 2.2) (P) versus a mean of 1.1 episodes/patient (SD 1.4) (TXA). The third study reported bleeding on 50% of days at risk (P) versus bleeding on 31% of days at risk (EACA).Two studies (68 patients) reported thromboembolism and no events occurred.All three studies reported a reduction in PlTx usage. The first study reported a difference of 222 platelet units (P) versus 69 platelet units (TXA). The second study only showed a difference in total platelet usage during consolidation chemotherapy, with a mean of 9.3 units (SD 3.3) (P) versus 3.7 (SD 4.1) (TXA). The third study reported one PlTx every 10.5 days at risk (P) versus one PlTx every 13.3 days at risk (EACA).Two studies reported red cell transfusion requirements and one study found a reduction in red cell transfusion usage.One study reported death due to bleeding as an outcome measure and none occurred.Only one study reported adverse events of TXA as an outcome measure and none occurred.None of the studies reported on the following pre-specified outcomes: overall mortality, adverse events of transfusion, disseminated intravascular coagulation (DIC) or quality of life (QoL).

AUTHORS' CONCLUSIONS

Our results indicate that the evidence available for the use of antifibrinolytics in haematology patients is very limited. The only available data suggest that TXA and EACA may be useful adjuncts to platelet transfusions so that platelet use, and the complications associated with their use, can be reduced. However, the trials were too small to assess whether antifibrinolytics increased the risk of thromboembolic events. Large, high-quality RCTs are required before antifibrinolytics can be demonstrated to be efficacious and safe in widespread clinical practice.

Topical application of tranexamic acid after adenoidectomy: a double-blind, prospective, randomized, controlled study

OBJECTIVE

Is to evaluate the efficacy of tranexamic acid when applied locally in children after primary isolated adenoidectomy with respect to intra-operative blood loss and post-operative bleeding.

STUDY DESIGN

Prospective, double-blind, randomized, controlled trial.

SETTING

Otolaryngology department, Tanta University and Tiba Hospitals, Egypt.

PATIENTS AND METHODS

Over three years, 400 children underwent primary isolated adenoidectomy followed by topical application of tranexamic acid (tranexamic acid group, 200 children) or saline (Placebo group, 200 children) with at least two weeks' follow up. Intra-operative blood loss and post-operative hemorrhage were monitored.

RESULTS

Both groups were almost equivalent in age and gender. The frequency of primary post-adenoidectomy hemorrhage as well as the rate of postnasal packing and blood transfusion required to manage severe bleeding were higher in placebo group. The volume of blood loss during surgery showed significant reduction in tranexamic acid group.

CONCLUSION

Topical application of tranexamic acid after adenoidectomy led to a significant reduction in blood loss during surgery and decreasing in the rate of post-operative bleeding as well as the need for postnasal packing and blood transfusion.

Platelet dose for prophylactic platelet transfusions

Although guidelines exist to deal with some aspects of platelet transfusion practice, many important clinical issues have not been addressed in large randomized controlled trials (RCTs). Slichter et al. conducted a RCT of prophylactic platelet transfusions to determine the effects of the dose of platelets on clinical signs of bleeding, the use of platelet and red cell transfusions, changes in the recipient's post-transfusion platelet count, days to next transfusion and adverse events (Effects of Prophylactic Platelet Dose on Transfusion Outcomes [PLADO] trial). The primary end point of the study (i.e., the percentage of patients in each group with at least one episode of bleeding of grade 2 or higher according to the WHO criteria) was not significantly different (71, 69 and 70% of patients in the low-, medium- and high-dose group, respectively). According to these data, one can conclude that the dose of platelets transfused has no significant effect on the incidence of bleeding in patients with hypoproliferative thrombocytopenia and platelet counts no greater than 10 × 10⁹/l.

Diagnosis and management of acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of the European LeukemiaNet

In 2003, an international working group last reported on recommendations for diagnosis, response assessment, and treatment outcomes in acute myeloid leukemia (AML). Since that time, considerable progress has been made in elucidating the molecular pathogenesis of the disease that has resulted in the identification of new diagnostic and prognostic markers. Furthermore, therapies are now being developed that target disease-associated molecular defects. Recent developments prompted an international expert panel to provide updated evidence- and expert opinion–based recommendations for the diagnosis and management of AML, that contain both minimal requirements for general practice as well as standards for clinical trials. A new standardized reporting system for correlation of cytogenetic and molecular genetic data with clinical data is proposed.

Transcutaneous arterial embolization to control massive tumor bleeding in head and neck cancer: 63 patients’ experiences from a single medical center

BACKGROUND

Massive tumor bleeding is a life-threatening complication in patients with head and neck cancer (HNC). Tumor hemorrhage is usually hard to localize, and medical management is often ineffective. Arterial angiography is used to visualize the source of bleeding, and concurrent transcutaneous arterial embolization (TAE) can be done to stop bleeding in some patients. We analyzed the outcome of TAE in HNC patients with massive bleeding at our institution.

METHOD

We retrospectively reviewed 93 angiographic procedures in 63 HNC patients. Factors potentially related to post-hemorrhagic survival were evaluated, including tumor stage (T, N, M), tumor type, previous curative-intent surgery, previous chemotherapy, previous radiotherapy, angiographic findings, the presence of embolization, and the embolization methods.

RESULT

A total 56 TAEs were done in 93 angiographic procedures in 63 HNC patients. The overall median post-hemorrhagic survival after angiography was 16 days (range 0-644 days). Median post-hemorrhagic survival for patients receiving TAE was 26 days (range 0-644 days), while patients who received angiography alone survived 8 days (range 0-144 days; p = 0.008). No factors other than TAE predicted post-hemorrhagic survival, and there were no major adverse events after TAE.

CONCLUSION

In our hands, TAE was associated with a low incidence of toxicities commonly attributable to the procedure such as stroke. Patients who were able to undergo TAE lived longer than those who were not candidates for the procedure.

Management of bleeding in patients with advanced cancer

Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.

Disseminated intravascular coagulation

OBJECTIVES

To provide an overview of the pathophysiology, manifestations, diagnosis, and treatment of disseminated intravascular coagulation (DIC) as it occurs in cancer.

DATA SOURCES

Published articles, research reports, and book chapters.

CONCLUSIONS

The syndrome of DIC is a serious hypercoagulation state that in its acute form may be life-threatening. The hemorrhage and intravascular coagulation that occur with DIC may lead to irreversible morbidity and mortality. Prompt recognition and emergency treatment are necessary to help minimize morbidity and mortality.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play an important role in early recognition of DIC to allow for prompt intervention. Nurses caring for patients affected by DIC will be providing complex nursing care, in addition to psychosocial support to patients and families.