Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery

Abstract

Background: In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete.

Objectives: To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures.

Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the last search: 20 November 2014.

Selection criteria: Randomised and quasi-randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention.

Data collection and analysis: Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta-analyses were performed on available and relevant data.

Main results: Of the 16 identified trials, four (112 participants) were eligible for inclusion.Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon-aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post-operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re-intervention was not reported by either trial.Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re-intervention). In one trial a high-dose rFVIIa regimen (90 μg/kg) was compared with a low-dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety.

Authors' conclusions: There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well-designed randomised controlled trials would be needed, in particular to address the cost-effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies.

1

Study flow diagram.

2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3

Forest plot of comparison: 1 Antifibrinolytic agents in people with haemophilia undergoing dental extractions, outcome: 1.1 Incidence of oral bleeding.

1.1. Analysis

Comparison 1 Antifibrinolytic agents in people with haemophilia undergoing dental extractions, Outcome 1 Incidence of oral bleeding.

1.2. Analysis

Comparison 1 Antifibrinolytic agents in people with haemophilia undergoing dental extractions, Outcome 2 Post‐operative replacement treatment administration.

2.1. Analysis

Comparison 2 Low‐dose vs high‐dose rFVIIa in people with haemophilia and inhibitors undergoing surgery, Outcome 1 Need for additional/alternative therapy.

3.1. Analysis

Comparison 3 Bolus infusion vs continuous infusion of rFVIIa in people with haemophilia and inhibitors undergoing surgery, Outcome 1 Participants with effective treatment.

4.1. Analysis

Comparison 4 Low‐dose vs high‐dose rFVIIa in people with haemophilia and inhibitors undergoing minor surgery, Outcome 1 Participants with effective treatment.

5.1. Analysis

Comparison 5 Low‐dose vs high‐dose rFVIIa in people with haemophilia and inhibitors undergoing major surgery, Outcome 1 Participants with effective treatment.