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28-02-2019 | Respiratory | News | Article

Antifibrinolytic therapy reduces haemoptysis admission in cystic fibrosis

medwireNews: Systemic antifibrinolytic therapy could help to reduce haemoptysis hospital admissions among patients with cystic fibrosis, suggests research.

The findings, published in Chest, show that enrolment of 21 patients with cystic fibrosis in a treatment pathway involving systemic antifibrinolytic therapy reduced the average annualized rate of haemoptysis admission by 50%, from 2.44 admissions per year prior to enrolment to 1.23 admissions per year afterwards.

A total of 72 distinct episodes of haemoptysis were treated and two-thirds of these were moderate (30–240 mL) or massive (>240 mL) in severity, according to the Cystic Fibrosis Foundation Pulmonary Therapies Committee guidelines.

The researchers, led by Hanny Al-Samkari (Massachusetts General Hospital in Boston, USA), note that “[u]nlike other studies examining the use of antifibrinolytic agents, our institutional pathway involves both outpatient and inpatient management.”

The patients were assessed for a median of 2.75 years  prior to receiving antifibrinolytic treatment  and a median of 1 year after starting treatment. Most of the patients had experienced more than 10 episodes of haemoptysis prior to starting antifibrinolytic treatment.

The treatments given were oral tranexamic acid (TXA) 650–1300 mg three times a day for 5 days or oral ε-aminocaproic acid (EACA) 500–1000 mg four times a day for 5 days for scant or mild haemoptysis, increasing to 1300 mg or 1000 mg, respectively, for moderate haemoptysis. For massive haemoptysis, EACA 4000–5000 mg was given intravenously every 4 to 6 hours until controlled and followed by oral TXA 1300 mg three times a day for 5 days or oral EACA 1000 mg four times a day for 5 days.

These 5-day treatment regimens were repeated as needed in the outpatient setting at the first sign of re-bleeding.

Bleeding stopped within a median of 2 days following antifibrinolytic treatment and tolerance of baseline airway clearance, as a measure of adequate haemostasis, occurred after a median of 5 days.

The researchers note that all five patients with an annualized haemoptysis admission rate of 1 episode or less per year prior to receiving antifibrinolytic treatment had no further admissions following treatment.

The improvement in admission rates appeared to be independent of other haemoptysis treatment strategies, such as holding hypertonic saline, dornase alfa, physiotherapy and antibiotics, all of which remained unchanged from pre- to post-antifibrinolytic treatment.

Al-Samkari and colleagues also report that in subgroup analyses the reduction in haemoptysis was similar among patients using and not using cystic fibrosis transmembrane conductance regulator modulators, and also for patients who needed or did not need bronchial artery embolization.

The treatment was well tolerated with no significant adverse effects. There was one case of central catheter-associated upper extremity deep vein thrombosis, but this was in a patient with a previous thrombosis in the same vessel.

The researchers comment: “In addition to preventing lung damage through limitation of hemorrhage, antifibrinolytic agents may have intrinsic anti-inflammatory effects systemically and specifically on lung tissue which could be of benefit to the [cystic fibrosis] chronic bronchial inflammatory state.”

They recommend a prospective, randomized, placebo-controlled study to confirm their findings and determine the magnitude of benefit.

By Lucy Piper

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