NIHR Signal Early use of tranexamic acid reduces bleeding more effectively

In people bleeding after trauma or giving birth, tranexamic acid within an hour of the start of bleeding increases the chances of survival by 72% compared with a placebo. Overall the trial data showed that at least six deaths from bleeding complications were prevented for every 1,000 people treated and potentially more if treatment is started early.




Tranexamic acid is an antifibrinolytic drug which reduces the breakdown of blood clots and is known to reduce serious bleeding. The researchers wanted to see if the benefits of tranexamic acid were greater if given as early as possible.




The current guidance recommends giving tranexamic acid for bleeding after trauma and in women with bleeding after giving birth. It is now clearer that every 15-minute delay after the first hour can reduce survival by about 10%.


From the NIHR Dissemination Centre

WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage

Postpartum haemorrhage (PPH) is a major cause of mortality, morbidity and long term disability related to pregnancy and childbirth. Effective interventions to prevent and treat PPH exist and can largely reduce the burden of this life-threatening condition.

Given the availability of new scientific evidence related to the use of tranexamic acid in the prevention and treatment of PPH, this document updates previous WHO recommendations.

Stopping antithrombotic therapy after acute upper gastrointestinal bleeding is associated with reduced survival

Postgraduate Medical Journal Published Online First: 03 November 2017. doi: 10.1136/postgradmedj-2017-135276

 

Antithrombotic drugs are often stopped following acute upper gastrointestinal bleeding (AUGIB) and frequently not restarted. The practice of antithrombotic discontinuation on discharge and its impact on outcomes are unclear.

The aim of this study was to assess whether restarting antithrombotic therapy, prior to hospital discharge for AUGIB, affected clinical outcomes.

UHCW Research: Monika Widlak

Emerging role of thalidomide in the treatment of gastrointestinal bleeding

Frontline Gastroenterology Published Online First: 02 November 2017. doi: 10.1136/flgastro-2017-100870

Thalidomide was initially synthesised in 1954 and marketed as a sedative and antiemetic for morning sickness. It was withdrawn in 1961 due to the realisation that it was teratogenic with over 10 000 children born with congenital abnormalities. Since then it has been used for treatment of dermatological and oncological conditions, including myeloma. In 1994, it was found to have a potent antiangiogenic effect via downregulation of vascular endothelial growth factor (VEGF). This has led to its use in gastrointestinal bleeding, as vascular abnormalities such as angiodysplasia have been found to have elevated VEGF levels. This article will review the current evidence of the use of thalidomide in bleeding associated with gastrointestinal vascular malformations, including angiodysplasia, gastric cancer and radiation-induced proctitis.

UHCW Research: Michael McFarlane, Lauren O’Flynn, Rachel Ventre and Benjamin R Disney

Management of Inherited Bleeding Disorders in Pregnancy

This guideline is intended for both specialist haematologists and obstetricians who have experience in managing pregnant patients with bleeding disorders. In addition, it may be a useful reference text for obstetric anaesthetists and neonatologists.

Women who have inherited bleeding disorders may be at significant risk of bleeding following miscarriage, abortion, antenatal procedures and delivery. They require multidisciplinary specialised care tailored to the individual, with cross-specialty communication, including anaesthetists and neonatologists as necessary.

The conditions covered in this guideline are haemophilia A and B, von Willebrand disease (VWD), factor XI deficiency, rare factor deficiencies, fibrinogen disorders, Bernard Soulier Syndrome (BSS), Glanzmann’s thrombasthenia (GT) and other platelet function disorders.

Drug reduces deaths from bleeding after childbirth

Tranexamic acid, given to women who bleed heavily after giving birth, reduced the risk of death by 31% when given within three hours.

This trial included 20,060 women with postpartum haemorrhage who were randomly assigned to receive tranexamic acid or placebo. This is the first large study to indicate that it is safe and implies it should be considered as an early drug option for postpartum haemorrhage. In keeping with other recent research, there was no increase in risk of blood clots.

From the NIHR Dissemination Centre

Factitious disorder: a rare cause of haematemesis

Clin J Gastroenterol (2017). https://doi.org/10.1007/s12328-017-0771-y

Acute upper gastrointestinal (GI) bleeding is a common condition in the UK with 50–70,000 admissions per year. In 20% of cases no cause can be found on endoscopy. Here, we present the case of a young female patient who was admitted on three occasions with large volume haematemesis and bleeding from other sites. She was extensively investigated and underwent multiple endoscopic procedures. She was eventually diagnosed with factitious disorder after concerns were raised about the inconsistent nature of her presentations. She was found to be venesecting herself from her intravenous cannula, and ingesting the blood to simulate upper GI bleeding. This is a rare cause of ‘haematemesis’ but perhaps not as rare as is thought.

UHCW Research: Jayne Eaden, Nicola Burch and Ben Disney

Risk of aspirin-related bleeding is higher in the over-75s

"People over 75 taking daily aspirin after a stroke or heart attack are at higher risk of major – and sometimes fatal – stomach bleeds than previously thought," BBC News reports.

The study involved around 3,000 adults from Oxford who were prescribed aspirin due to previous heart attack or stroke. Researchers followed these patients for up to 10 years to see how many of them were admitted to hospital with bleeds.

They found that for under-75s the annual risk of bleeding is around 1%. However adults over the age of 75 have three times the risk of a major bleed compared with younger adults, particularly bleeds of the stomach and upper digestive tract.

The researchers estimate that routinely prescribing proton pump inhibitor (PPIs) could drastically reduce these risks in older adults. PPIs are drugs that help protect the lining of the stomach and so reduce the risk of a bleed.

RCOG statement on drug treatment for excessive blood loss after childbirth

A major trial published in The Lancet shows that a cheap and widely available medication can reduce deaths from severe bleeding after childbirth, the leading cause of maternal mortality worldwide. The study of 20,000 women from 21 countries shows that maternal deaths were reduced by 31%, and urgent surgery to stop life-threatening bleeding was decreased by 36%, if the tranexamic acid was given within three hours of delivery.

Professor Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said:

"The results of this important trial are very welcome and show that early administration of a cheap, widely available and heat-stable drug can reduce the number of maternal deaths from excessive bleeding after childbirth, also known as postpartum haemorrhage (PPH). The medication can also reduce the need for urgent surgery to stop life-threatening bleeding. "

Tranexamic acid in epistaxis - who bloody nose?

New from BestBETs

In [adults without a bleeding disorder who have uncomplicated epistaxis] is [tranexamic acid] effective at [stopping bleeding and/or preventing rebleeding]?

The evidence is not sufficient to advise the routine use of tranexamic acid for patients attending ED with epistaxis. The evidence available is conflicting and there is a lack of sufficiently robust, well-designed trials on the topic to allow a recommendation to change current practice to include tranexamic acid. However, it is important to note that there is no evidence of tranexamic acid for epistaxis causing an increase in adverse events and the most robust study available currently shows a potential benefit. As such it is an area where more research would be beneficial. From the evidence available, it would seem that using the injectable form of tranexamic acid as a topical treatment would be the most likely to be beneficial and should be the starting point for future research. It may also be reasonable from the evidence currently available to offer topical tranexamic acid to patients such as the one in the clinical scenario above where the standard treatment of nasal packing is unacceptable to the patient.