Anti-fibrinolytics for mucosal bleeding in adults with life-limiting illnesses: a systematic review.

Introduction: Patients with life-limiting illnesses are at increased risk of mucosal bleeding. Usual management includes anticipatory planning and sedation, alongside anti-fibrinolytics, despite a lack of evidence for their use. Anti-fibrinolytic agents (tranexamic acid and aminocaproic acid) produce effective haemostasis in different clinical settings. Our aim was to synthesise the evidence for anti-fibrinolytic medication use in adult patients with life-limiting illnesses at risk of, or experiencing, mucosal bleeding.

Methods: We searched MEDLINE, Embase, CINAHL, Web of Science Conference Proceedings Citation Index, Cochrane Library databases and clinical trial registries (inception to January 2024) to identify studies investigating the use of anti-fibrinolytics in patients with life-limiting illnesses. Results were screened against a priori inclusion criteria, data ere extracted, and quality was appraised using a CASP (Critical Appraisal Skills Programme) checklist or BMJ risk of bias assessment. Data were analysed using narrative synthesis.

Results: Five studies meeting our search criteria (one cohort and four case series) were included. Data relating from 87 patients were used in narrative synthesis. Anti-fibrinolytic therapy was used for active mucosal bleeding in 37 patients, of whom 30 achieved total bleeding cessation. Fifty patients received prophylactic anti-fibrinolytics, of whom 32 experienced no bleeding events. Adverse events were reported in 3 of 87 patients (arterial thrombus, severe thrombocytopenia and stomach cramps). Mortality and quality of life were not reported.

Conclusion: Anti-fibrinolytics are generally well tolerated within this population and may prevent and reduce mucosal bleeding. Further high-quality research is suggested to investigate current practice and to compare anti-fibrinolytic with placebo in the management of bleeding in patients with life-limiting illnesses.

Prospero registration number: CRD42022325529.