High-dose Continuous Infusion of Tranexamic Acid for Controlling Life-threatening Bleed in Advanced Cancer Patients

Anti-fibrinolytics for mucosal bleeding in adults with life-limiting illnesses: a systematic review

INTRODUCTION

Patients with life-limiting illnesses are at increased risk of mucosal bleeding. Usual management includes anticipatory planning and sedation, alongside anti-fibrinolytics, despite a lack of evidence for their use. Anti-fibrinolytic agents (tranexamic acid and aminocaproic acid) produce effective haemostasis in different clinical settings. Our aim was to synthesise the evidence for anti-fibrinolytic medication use in adult patients with life-limiting illnesses at risk of, or experiencing, mucosal bleeding.

METHODS

We searched MEDLINE, Embase, CINAHL, Web of Science Conference Proceedings Citation Index, Cochrane Library databases and clinical trial registries (inception to January 2024) to identify studies investigating the use of anti-fibrinolytics in patients with life-limiting illnesses. Results were screened against a priori inclusion criteria, data ere extracted, and quality was appraised using a CASP (Critical Appraisal Skills Programme) checklist or BMJ risk of bias assessment. Data were analysed using narrative synthesis.

RESULTS

Five studies meeting our search criteria (one cohort and four case series) were included. Data relating from 87 patients were used in narrative synthesis. Anti-fibrinolytic therapy was used for active mucosal bleeding in 37 patients, of whom 30 achieved total bleeding cessation. Fifty patients received prophylactic anti-fibrinolytics, of whom 32 experienced no bleeding events. Adverse events were reported in 3 of 87 patients (arterial thrombus, severe thrombocytopenia and stomach cramps). Mortality and quality of life were not reported.

CONCLUSION

Anti-fibrinolytics are generally well tolerated within this population and may prevent and reduce mucosal bleeding. Further high-quality research is suggested to investigate current practice and to compare anti-fibrinolytic with placebo in the management of bleeding in patients with life-limiting illnesses.

PROSPERO REGISTRATION NUMBER

CRD42022325529.

Repurposing Tranexamic Acid as an Anticancer Agent

Tranexamic Acid (TA) is a clinically used antifibrinolytic agent that acts as a Lys mimetic to block binding of Plasminogen with Plasminogen activators, preventing conversion of Plasminogen to its proteolytically activated form, Plasmin. Previous studies suggested that TA may exhibit anticancer activity by blockade of extracellular Plasmin formation. Plasmin-mediated cleavage of the CDCP1 protein may increase its oncogenic functions through several downstream pathways. Results presented herein demonstrate that TA blocks Plasmin-mediated excision of the extracellular domain of the oncoprotein CDCP1. In vitro studies indicate that TA reduces the viability of a broad array of human and murine cancer cell lines, and breast tumor growth studies demonstrate that TA reduces cancer growth in vivo. Based on the ability of TA to mimic Lys and Arg, we hypothesized that TA may perturb multiple processes that involve Lys/Arg-rich protein sequences, and that TA may alter intracellular signaling pathways in addition to blocking extracellular Plasmin production. Indeed, TA-mediated suppression of tumor cell viability is associated with multiple biochemical actions, including inhibition of protein synthesis, reduced activating phosphorylation of STAT3 and S6K1, decreased expression of the MYC oncoprotein, and suppression of Lys acetylation. Further, TA inhibited uptake of Lys and Arg by cancer cells. These findings suggest that TA or TA analogs may serve as lead compounds and inspire the production of new classes of anticancer agents that function by mimicking Lys and Arg.

Epidemiology of Bleeding in Critically Ill Children With an Underlying Oncologic Diagnosis

Supplemental Digital Content is available in the text.

Critically ill children with malignancy have significant risk of bleeding but the exact epidemiology is unknown. We sought to describe severe bleeding events and associated risk factors in critically ill pediatric patients with an underlying oncologic diagnosis using the newly developed Bleeding Assessment Scale in Critically Ill Children definition.