We asked, and you answered! Here are the responses from this month’s “You Make the Call” question on what prophylactic treatment you'd recommend for a basketball player with multiple hematoma episodes.
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.
I do not think prophylaxis with recombinant FVIIa or FFP would be practical or feasible. TXA has proven useful for treatment or prevention of bleeding in these patients in other settings (such as for menorrhagia, mouth bleeding, or postpartum care), so it might be worth trying either alone or in combination with any other treatments. Regular treatment with FXI infusions might be another possibility. The half-life of FXI is about 48 hours (or about two days), so intermediate, tentative doses of FXI concentrate (10-15 IU/kg) before basketball once a week with FXI monitoring might be a possibility. However, increased thrombotic risk with this product should be discussed, and FXI concentrate is not available in certain settings. Realistically, I think a trial with TXA would be the best option.
Carlos Aguilar, MD
Soria, Spain
Routine prophylaxis is not necessary unless patients are undergoing major surgery with an FXI level of less than 20% or a history of trauma or significant bleeding. Also, the target FXI level is greater than 40%. Prophylactic recombinant FVIIa or TXA would be useful for procedures with high fibrinolytic activity such as dental, nasal, or genitourinary. The patient should refrain from antiplatelets and NSAIDs and avoid contact sports like basketball or lacrosse.
Israr Khan, M
Chicago, IL
I would recommend prophylactic FFP prior to games because his FXI level is low but not too low and he has only bled during sports. I would not recommend recombinant FVIIa or TXA as prophylactic therapy.
I would advise the patient to change his sport but would not preclude him. The goal should always be to return patients to their normal activities because precluding them changes their routines.
Humberto Villefort, MD
Campinas, Brazil
I would use prophylactic tranexamic acid with games and consider factor VIIa with trauma.
Loree M. Larratt, MD
Edmonton, Canada
I would recommend a noncontact sport.
Philip L. Cimo, MD
Houston, TX
I would recommend 1300 mg of tranexamic acid twice a day on the day of and the day after games, maybe longer depending on response.
Kelty R. Baker, MD
Houston, TX
Make a diagnosis first! Have you ordered platelet function studies or an angiogram? Has Ehlers-Danlos syndrome been ruled out?
I would not offer prophylaxis. It might be best if the patient doesn’t play basketball.
Frank Beardell, MD
Wilmington, DE
My recommendation is 1 mg of tranexamic acid 12 hours before the game and every six hours, up to 24 hours after the game. If you don’t have good results with this treatment, I recommend 8 mg of activated recombinant factor VII concentrate one hour before the game and one hour after the end of the game.
Jussara Almeida, MD
Sao Paolo, Brazil
I don’t recommend prophylactic fresh frozen plasma before the games. I recommend treatment only with injury and would use tranexamic acid as prophylaxis. I think this patient should consider stopping basketball.
Jorge Oliveros-Alvear, MD, MMSc
Guayaquil, Ecuador
I would have him wear thigh pads under his shorts.
A factor XI level of 43% does not seem very low.
James Shikle, MD
Evans, GA
I recommend prophylactic fresh frozen plasma before a basketball game.
Canan Albayrak, MD
Samsun, Turkey
College basketball can be a very physical sport with frequent trauma. If allowed by the college health service, a single dose of recombinant factor VIIa at 30 mcg/kg would be protective for a full game. I would avoid plasma. Tranexamic acid would not compensate for the role of factor XI in supporting thrombin generation.
Howard Liebman, MD, MA
Los Angeles, CA
I would not recommend treatment with fresh frozen plasma, but would recommend tranexamic acid before games.
Emna Hammami, MD
Tunis, Tunisia
