Recombinant factor VIIa as an adjunctive therapy for patients requiring large volume transfusion: a pharmacoeconomic evaluation

Evaluation of recombinant factor VIIa treatment for massive hemorrhage in patients with multiple traumas

Background

Recent studies and case reports have shown that recombinant factor VIIa (rFVIIa) treatment is effective for reversing coagulopathy and reducing blood transfusion requirements in trauma patients with life-threatening hemorrhage. The purpose of this study is to evaluate the effect of rFVIIa treatment on clinical outcomes and cost effectiveness in trauma patients.

Methods

Between January 2007 and December 2010, we reviewed the medical records of patients who were treated with rFVIIa (N=18) or without rFVIIa (N=36) for life-threatening hemorrhage due to multiple traumas at the Emergency Department of Pusan National University Hospital in Busan, Korea. We reviewed patient demographics, baseline characteristics, initial vital signs, laboratory test results, and number of units transfused, and then analyzed clinical outcomes and 24-hr and 30-day mortality rates. Thromboembolic events were monitored in all patients. Transfusion costs and hospital stay costs were also calculated.

Results

In the rFVIIa-treated group, laboratory test results and clinical outcomes improved, and the 24-hr mortality rate decreased compared to that in the untreated group; however, 30-day mortality rate did not differ between the groups. Thromboembolic events did not occur in both groups. Transfusion and hospital stay costs in the rFVIIa-treated group were cost effective; however, total treatment costs, including the cost of rFVIIa, were not cost effective.

Conclusions

In our study, rFVIIa treatment was shown to be helpful as a supplementary drug to improve clinical outcomes and reduce the 24-hr mortality rate, transfusion and hospital stay costs, and transfusion requirements in trauma patients with life-threatening hemorrhage.

[Successful use of recombinant factor VIIa in the control of a massive bleeding in two patients with biventricular assist device (Thoratec)]

Massive bleeding is a dreaded complication of biventricular mechanical assistance implantation. Its origin is multifactorial. Blood products transfusion associated with correction of coagulopathy are sometimes insufficient. We report two cases of massive bleeding after a Thoratec biventricular assistance implantation. After surgical haemostasis failure and despite the correction of coagulation disorders, a major bleeding persisted, so these patients received a single injection of 90 microg/kg of rFVIIa. This allowed in both cases a significant reduction of the bleeding and the restoration of normal haemodynamic conditions. This treatment was not complicated by any thrombotic accident.

Role of factor VII in correcting dilutional coagulopathy and reducing re-operations for bleeding following non-traumatic major gastrointestinal and abdominal surgery

OBJECTIVE

The objective of this study is to evaluate the effectiveness of rfVIIa in reducing blood product requirements and re-operation for postoperative bleeding after major abdominal surgery.

BACKGROUND

Hemorrhage is a significant complication after major gastrointestinal and abdominal surgery. Clinically significant bleeding can lead to shock, transfusion of blood products, and re-operation. Recent reports suggest that activated rfVIIa may be effective in correcting coagulopathy and decreasing the need for re-operation.

METHODS

This study was a retrospective review over a 4-year period of 17 consecutive bleeding postoperative patients who received rfVIIa to control hemorrhage and avoid re-operation. Outcome measures were blood and clotting factor transfusions, deaths, thromboembolic complications, and number of re-operations for bleeding.

RESULTS

Seventeen patients with postoperative hemorrhage following major abdominal gastrointestinal surgery (nine pancreas, four sarcoma, two gastric, one carcinoid, and one fistula) were treated with rfVIIa. In these 17 patients, rfVIIa was administered for 18 episodes of bleeding (dose 2,400-9,600 mcg, 29.8-100.8 mcg/kg). Transfusion requirement of pRBC and FFP were each significantly less than pre-rfVIIa. Out of the 18 episodes, bleeding was controlled in 17 (94%) without surgery, and only one patient returned to the operating room for hemorrhage. There were no deaths and two thrombotic complications. Coagulopathy was corrected by rfVIIa from 1.37 to 0.96 (p < 0.0001).

CONCLUSION

Use of rfVIIa in resuscitation for hemorrhage after non-traumatic major abdominal and gastrointestinal surgery can correct dilutional coagulopathy, reducing blood product requirements and need for re-operation.

Use of rFVIIa for critical bleeding in cardiac surgery: dose variation and patient outcomes

BACKGROUND AND OBJECTIVES

Recombinant activated factor VIIa (rFVIIa) is increasingly being used in non-haemophiliac patients for the treatment of severe bleeding refractory to standard interventions. Optimal dosing regimens remain debated in cardiac surgery. Therefore, this study investigated the use of different rFVIIa dosing practices on response to bleeding and patient outcomes in cardiac surgery patients using data from the Haemostasis Registry.

METHODS

Data were extracted from the Haemostasis Registry that records cases of off-licence rFVIIa use in participating institutions. Univariate analyses compared patients receiving < or =40 microg/kg, 41-60 microg/kg, 61-80 microg/kg, 81-100 microg/kg and >100 microg/kg of rFVIIa on key parameters. Logistic regression models investigated the relationship between independent variables and 28-day mortality.

RESULTS

Complete data was available on 804 cardiac surgery patients who received rFVIIa. Of these, 42 (5.2%) were treated with doses < or =40 microg/kg, while the dose group containing the most patients was 81-100 microg/kg (368, 45.77%). Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality.

CONCLUSIONS

These findings raise the important question of whether lower doses of rFVIIa may be as effective as higher doses in the treatment of severe bleeding in cardiac surgery patients.

Reversal of coagulopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa is more cost-effective than plasma

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of death and disability after trauma. Coagulopathy is common in this patient population and requires rapid reversal to allow for safe neurosurgical intervention and prevent worsening of the primary injury. Typically reversal of coagulopathy is accomplished with the use of plasma. Recombinant factor VIIa (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) has become increasingly used "off-label" in patients with neurosurgical emergencies to rapidly reverse coagulopathy. We hypothesized that the use of rFVIIa in this patient population would prove to be cost-effective as well as demonstrate clinical benefit.

METHODS

The trauma registry at the R Adams Cowley Shock Trauma Center was used to identify all coagulopatic trauma patients admitted between January 2002 and December 2007 with relatively isolated TBI (head Abbreviated Injury Scale score of >or=4). The medical records of patients were reviewed and demographics, injury-specific data, medications administered, laboratory values, blood product utilization, neurosurgical procedures, length of stay (LOS), discharge disposition, and outcome data were abstracted. Patients who received rFVIIa for reversal of coagulopathy were compared against those who did not receive rFVIIa. t Tests were used to compare differences between continuous variables, and chi2 analysis was used to compare categorical variables. A p value of <0.05 was considered significant for all statistical tests.

RESULTS

During a 6-year period, there were 179 patients who met inclusion criteria. One hundred eleven patients (62.0%) were treated with conventional therapy alone whereas 68 (38.0%) received rFVIIa. Baseline characteristics between the two groups were similar except that Injury Severity Score and admission International normalized ratio were higher in the rFVIIa group and the rFVIIa group had a higher percentage of patients with head Abbreviated Injury Scale score of 5 injuries, patients who underwent neurosurgical procedures and patients with preinjury warfarin use. There was no difference in total charges between these groups (mean US $63,403 in the conventionally treated group vs. $66,086). When patients who required admission to the intensive care unit were analyzed (n = 110, 50% received rFVIIa), total mean charges and costs were significantly lower in the group that received rFVIIa (mean US $108,900 vs. $77,907). Hospital LOS, days of mechanical ventilation, and plasma utilization were lower in the rFVIIa group. Mortality and thromboembolic complication rates were not different between the two groups.

CONCLUSION

In this study, we were able to demonstrate a significant economic benefit of the use of rFVIIa for reversal of coagulopathy in severely injured patients with TBI. Not all patients with coagulopathy and an anatomic brain injury benefit, but in patients who are neurologically or physiologically compromised, using rFVIIa decreases total charges and costs of hospitalization. This decrease in overall cost is directly attributable to the significant decrease in LOS and decrease in the need for mechanical ventilation. This study demonstrates that in coagulopathic patients with TBI who require intensive care unit admission, rFVIIa is cost-effective and safe. Prospective studies are needed to confirm these findings and establish clinical effectiveness.

Recombinant activated factor VIIa for the treatment of bleeding in major abdominal surgery including vascular and urological surgery: a review and meta-analysis of published data

Background

The purpose of this study was to determine the role of recombinant activated factor VII (rFVIIa) in abdominal, vascular, and urological surgery.

Methods

We conducted meta-analyses of case series and placebo-controlled studies reporting on the treatment or prophylaxis of bleeding with rFVIIa regarding 'reduction or cessation of bleeding', 'mortality', and 'thromboembolism'.

Results

All case reports (n = 15 case reports and 17 patients) documented an effect of rFVIIa in the treatment of bleeding. A meta-analysis of 10 case series revealed a reduction or cessation of bleeding in 39 out of 50 patients after administration of rFVIIa (estimated mean effect 73.2%, 95% confidence interval [CI] 51.0% to 95.4%) and a mean probability of survival of 53.0% (95% CI 26.4% to 79.7%). Among the rFVIIa responders, 19 out of 29 patients (66%) survived versus 1 out of 10 rFVIIa nonresponders (P = 0.003). Six out of 36 patients from the case series had a thromboembolic complication (estimated mean probability 16.5%, 95% CI 1.2% to 31.8%). Compared with a meta-analysis of eight placebo-controlled studies, no increased risk of thromboembolism was seen after administration of rFVIIa.

Conclusion

The meta-analysis of case series showed that, in a mean of 73% patients, rFVIIa achieved at least a reduction of bleeding and that the probability of survival is increased in patients responding to rFVIIa. rFVIIa was not associated with an increased risk of thromboembolism compared with placebo.

Recombinant activated factor VII (Novo7) in patients with ventricular assist devices: case report and review of the current literature

Postoperative bleeding might become a serious problem in the management of cardiac surgical patients, with marked medical and economic impact. In these life-threatening situations, massive haemorrhage represents frequently a combination of surgical and coagulopathic bleeding. Surgical bleeding results from a definite source at the operation site and can be corrected using surgical standard techniques. Acute coagulopathies, in contrast, result from impaired thrombin formation, and require optimized therapeutical strategies. Effective pharmacological treatment will be complicated by the presence of ventricular assist devices (VAD), which necessarily imply effective anticoagulation. In episodes of uncontrolled coagulopathic bleeding, the application of recombinant activated factor VII (rFVIIa) as a effective haemostatic agent has become more and more popular. However, only very few data are available on its use in patients with VAD in place. We researched the PubMed-database for case reports about the use of rFVIIa in patients with VAD and summarized them. In addition, we report a case from our hospital. In all cases cessation of bleeding without any thrombembolic complications could be achieved. In cases of uncontrollable, non-surgical bleeding rFVIIa seems to be a therapeutical option even for patients with VAD.

Use of Recombinant Factor VIIa During Excision of Vascular Anomalies

BACKGROUND

The surgical excision of vascular anomalies is often accompanied with significant perioperative bleeding. Novel hemostatic agents, including recombinant factor VIIa (rVIIa), have been shown to reduce bleeding in hemophilia and trauma patients along with decreasing blood loss during various surgical procedures. The role of rVIIa during excision of vascular anomalies has not been examined.

METHODS

A retrospective chart review of patients from 2001 to 2003 who received perioperative rVIIa during excision of vascular anomalies at one institution.

RESULTS

Nine patients were identified who received perioperative rVIIa during removal of their vascular anomalies (7 venous malformations, 1 lymphatic-venous malformation, 1 arteriovenous malformation). All patients received at least one dose of rVIIa during the perioperative period (2/9 received 2 doses). An accurate account of hourly blood loss was reported, and could be graphed, in three patients. These patients displayed significant reductions in hourly blood loss after the administration of rVIIa. These cases are detailed in this report. Surgeons reported subjective improvements in operative bleeding, efficiency, and operative time in six of six patients after the administration of rVIIa intraoperatively. Reduced postoperative bleeding was reported in two patients who received rVIIa for persistent drain output.

CONCLUSION

rVIIa may be an effective adjunct in improving the surgical efficiency and outcome of excised vascular anomalies.

Concentration of transfusion resources on a few pathologies and a few patients: analysis of the comprehensive in-hospital patient database

BACKGROUND

Blood is a sparse commodity. Transfusion needs increase while the number of donors decreases. These constraints incite Belgian authorities to pay more attention to transfusion financing. This implies pathologic knowledge of the epidemiology of in-hospital transfusion and the consumption of blood products.

STUDY DESIGN AND METHODS

This study is a retrospective analysis of in-hospital stays from the year 2000 and includes data from all 124 Belgian hospitals. The database contains information on diagnoses, procedures, and all-patients refined diagnosis-related groups (APRDRGs) but also on expenses linked to blood products transfused and to transfusion-related pharmaceutical products.

RESULTS

Three percent of surgical patients used 55.7 percent of transfusion resources and 75.4 percent of transfusion costs were associated with 24 APRDRGs. In the medical group, 3 percent of the patients accounted for 80.2 percent of transfusion costs and 20 APRDRGs consumed 71.9 percent of transfusion resources. The variables with the highest impact on the proportion of patients transfused were severity, pathology, and age. The effect of hospitals remained significant but had less impact. No substitution of blood products by transfusion-related pharmaceutical products was observed in our analysis.

CONCLUSION

Our study confirms that transfusion now centers on a limited number of pathologic entities and, within those, in small subsets of patients. This implies that the costs linked to setting up and running the transfusion system can no longer be shared by a large number of patients who receive transfusions but rely increasingly on patients at higher risks of more unpredictable needs. The system must nevertheless be able to cope with them at any time.

Use of recombinant activated factor VII in massive obstetric haemorrhage

Massive obstetric haemorrhage is a life-threatening emergency that remains a major cause of maternal mortality. Conventional management is aimed at optimising uterine tone, replacing circulating volume and blood products, and surgery to achieve haemostasis. Recently there have been numerous reports of the (unlicensed) use of recombinant activated factor VII in the management of major obstetric haemorrhage. We report our experience of using it in the treatment of major post-partum haemorrhage in four previously healthy parturients. The published reports of recombinant activated factor VII use in post-partum haemorrhage (unrelated to pre-existing coagulopathies) are compared.

The economics of blood: Gift of life or a commodity?

Objectives:To calculate the costs of blood collection, testing, storage, and transfusion in Greece.

Methods:Costing information was collected from two large public hospitals, in Athens and Crete, that also act as blood banks. Given that private health care accounts for 40 percent of total health spending, the same costs were also considered in a private setting by collecting key reagent cost data from a leading private hospital in Athens. Mainly direct costs were considered (advertising campaigns, personnel, storage and maintenance, reagent costs, transportation costs from blood bank to end-use hospitals, and cross-matching and transfusion costs in receiving hospitals) and some indirect costs (opportunity cost of blood donorship).

Results:Captive donorship accounts for over 50 percent of the national blood supply. A unit of blood transfused would cost between €294.83 and €339.83 in public hospitals and could reach €413.93 in a private facility. This figure may be an underestimate, as it excludes opportunity costs of blood transfusion for patients and the healthcare system.

Conclusions:Blood has a significant cost to the health system. Policy makers and practitioners should encourage its rational use, build on current policies to further improve collection and distribution, encourage further volunteer donorship in Greece, and also consider alternatives to blood where the possibility exists.

Determinants of complications with recombinant factor VIIa for refractory blood loss in cardiac surgery

PURPOSE

Recombinant factor VIIa (rFVIIa) is being used for refractory, excessive blood loss (EBL) after cardiac surgery, but its safety for this indication is not known.

METHODS

The unadjusted and risk-adjusted adverse event (AE) rates were compared between 114 consecutive cardiac surgical patients who received rFVIIa for refractory EBL and 541 concurrent patients who developed EBL but did not receive rFVIIa. Similarly, timing of rFVIIa therapy was assessed by dichotomizing rFVIIa patients based on median number of red blood cell (RBC) units received before therapy. The measured AE was a composite of death, stroke, renal failure, myocardial infarction, and major vein thrombosis. For risk adjustment, logistic regression models for this outcome were constructed using known predictors of AEs.

RESULTS

The median RBC units transfused before rFVIIa therapy was eight. The AE rates in the untreated, early (< or = 8 U), and late (> 8 U) treated patients were 24% (129/541), 30% (20/66), and 60% (29/48). The risk-adjustment model included total RBC units, pump time, weaning difficulty, gender, weight, and age. The unadjusted and adjusted AE odds ratios (OR) in the treated vs untreated groups were 2.41 [confidence interval (CI) 1.58-3.67; P < 0.0001] and 1.04 (CI 0.60-1.81; P = 0.9). In the rFVIIa group, the adjusted AE OR was lower in the early treated group (OR 0.41; CI 0.18-0.92; P = 0.03).

CONCLUSION

In cardiac surgical patients with refractory hemorrhage, rFVIIa therapy is not associated with increased risk of AEs, and early treatment may be associated with better outcomes.