Consensus on Sclerotherapy for Patients With Hereditary Hemorrhagic Telangiectasia-Related Epistaxis

Abstract

Importance: Sclerotherapy involves injecting a sclerosing agent into the nasal, oral mucosa, and cutaneous telangiectasias to reduce bleeding, demonstrating both safety and efficacy as a treatment. Despite its proven benefits, few physicians currently offer this therapy to patients with hereditary hemorrhagic telangiectasia (HHT).

Objective: To promote the safe use of sclerotherapy among patients with HHT.

Design, setting, and participants: In this survey study, a modified Delphi protocol was used to achieve consensus on sclerotherapy among a panel of 6 experts. The Delphi consensus took place through online meetings and surveys sent via Google Forms. Six experts from Italy, Spain, and the US, each with more than 10 years of experience in the use of sclerotherapy for HHT-associated epistaxis and cutaneous telangiectasias, participated in the Delphi protocol.

Main outcomes and measures: This approach included 3 rounds of ratings interspersed with an in-person discussion led by an experienced moderator to resolve disagreements. Experts in using specific sclerotherapy agents (sodium tetradecyl sulfate and polidocanol), both in liquid or foam form, participated in surveys. Consensus was defined as agreement among 4 of 6 panelists. After discussions and clarifications, 3 survey rounds were conducted, resulting in consensus on all 30 statements across 7 domains.

Results: The consensus among 6 experts indicates that stable patients with HHT are eligible for sclerotherapy, with individualized precautions based on medical history and comorbidities. In-office sclerotherapy provides several advantages, including quick access, high patient satisfaction, and the elimination of general anesthesia risks, despite the occasional occurrence of vasovagal events and moderate bleeding. According to the 2015 European Society of Cardiology guideline, antibiotic prophylaxis is recommended for patient preparation, while fasting is generally not necessary. Specific precautions for preventing complications such as septal perforation and amaurosis were identified. Adverse effects are usually mild to moderate, with severe bleeding being rare. Practitioners should have expertise in endoscopy or rhinoscopy, thorough pathology knowledge, and training from experienced professionals.

Conclusions and relevance: In this survey study, the consensus of 6 experts produced 30 statements guiding patient care and safe procedure implementation. While not formal treatment guidelines, these statements offer valuable insights for clinicians seeking to adopt or align with expert recommendations. Further validation and research are encouraged to ensure these consensus statements improve patient care and outcomes.