PB1047 - A patient with severe, refractory ITP and GI bleeding is kept hemodynamically stable over days with a combination therapy of tranexamic acid, recombinant FVIIa, F XIII and red blood cell concentrates

Background: Severe bleeding complications in ITP are rare but often related to therapy refractoriness. Reliable measures to bridge for bleeding complications during severe thrombopcytopenia are therefore important, not only for ITP patients, but also for other states of severe thrombocytopenia.

Aims: To describe our experiences with a combination of measures to increase thrombin generation along with fibrin cross linking and fibrinolysis suppression in a patient with refractory ITP that had just underwent splenectomy. The therapeutic approach from an anesthesiology point of view has been described elsewhere (Meyer et al. [Emergency treatment of severe bleeding in immune thrombocytopenia]. Anaesthesist 2021).

Methods: In a patient with severe ITP after splenectomy, regularly scheduled (hemostatic) combination therapy of tranexamic acid, rFVIIa and FXIII concentrate together with red cell concentrates (figure 1) was used to reduce and bridge active bleeding in an attempt to gain time for a response to splenectomy, together with a TPO agonist and immunosuppression.

Results: Unfortunately, thrombocytopenia did not recover despite splenectomy, TPO and immunosuppression. However, the above mentioned therapy allowed to keep the patient hemodynamically stable for 5 days after splenectomy despite severe thrombocytopenia and continuous gi blood loss. On day 7, the patient decided against further treatment.
As soon as this combination therapy was stoped, the patient began to bleed profusely from the gi tract, became hemodynamically unstable and rapidly succumbed to the greatly enhanced bleeding.

Conclusion(s): This case indicates that ITP, in few cases, can become impossible to treat.
This case also illustrates that combination therapy of rFVIIa and FXIII (and here plus TXA) is feasible and seems to be a very potent procoagulant combination that can, together with the use of labile blood products, be used to salvage certain bleeding patients for some time.
However, great diligence is needed given the apparent potency of this combination, in order to prevent thromboembolic events.