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