ASH Clinical News November 2015 | Page 56

You Make the Call Each month in “You Make the Call,” we’ll pick a challenging clinical question submitted through the Consult-a-Colleague program and post the expert’s response. But, what would YOU do? We’ll also pose a submitted question and ask you to send your responses. See how your answer matches up to the experts in the next print issue. This month, Anne T. Neff, MD, answers a question about tranexamic acid for pre- and peri-operative anticoagulation. Clinical Dilemma: I have seen several orthopedic surgeons give tranexamic acid before and during surgery. One surgeon did not even hold the warfarin. Is this the standard now? Next Month’s Clinical Dilemma: Do you consider TBO–filgrastim identical, in terms of response and tolerance, to filgrastim? Is it correct to switch 300 µg filgrastim to 300 µg TBO–fil grastim? How would you respond? Email us at [email protected]. Experts Make the Call Consult a Colleague Through ASH Anne T. Neff, MD Department of Hematology/Medical Oncology Cleveland Clinic Cleveland, Ohio Consult a Colleague is a service for ASH members that helps facilitate the exchange of information between hematologists and their peers. ASH members can seek consultation on clinical cases from qualified experts in 11 categories: I would never pretend to know the standard approach among orthopedic surgeons, but I have observed the same practices. Most large-joint orthopedic surgeries (hip or knee joint replacement) are complicated by significant blood loss and the need for allogeneic blood transfusions to treat symptomatic post-operative anemia. Transfusion, in turn, is associated with other complications such as wound infections and inflammation. To curb blood loss, many major orthopedic procedures now include intravenous or topical use of tranexamic acid, a lysine analog that competitively inhibits the activation of plasminogen to plasmin, thus decreasing fibrinolytic activity. Tranexamic acid has been very successful at decreasing blood loss and the need for transfusion and, subsequently, lowering the risk of post-operative anemia. Fortunately, this has not come at the price of increased venous thromboembolism – a significant potential threat to any major joint surgery. Anticoagulation with tranexamic acid is still instituted in the standard fashion. Because of the potential risk of increased vascular occlusion, the major trials of tranexamic acid in orthopedic surgeries have barred the participation of patients with a history of venous or arterial thrombosis.1 In a trial of trauma patients where no such exclusions were made, there was no increased incidence of thrombosis in the patients who received tranexamic acid;2 therefore, in my consulting practice, I have recommended against it only with very hypercoagulable patients. References 1. K im C, Park SS, Davey JR. Tranexamic acid for the prevention and management of orthopedic surgical hemorrhage: current evidence. J Blood Med. 2015;6:239-44. 2. C RASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23-32. 54 ASH Clinical News • Anemias • Hematopoietic cell transplantation • Hemoglobinopathies • Hemostasis/thrombosis • Lymphomas • Lymphoproliferative disorders • Leukemias • Multiple myeloma & Waldenström macroglobulinemia • Myeloproliferative Disorders • Myelodysplastic Syndromes • Thrombocytopenias Assigned volunteers (“colleagues”) will respond to inquiries within two business days (either by email or phone). Have a puzzling clinical dilemma? Submit a question, and read more about Consult-a-Colleague volunteers at hematology.org/Clinicians/Consult.aspx or scan the QR code. DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk. *If you have a request related to a hematologic disorder not listed here, please email your recommendation to ashconsult@ hematology.org so it can be considered for addition in the future. November 2015