(487) Management of Diffuse Alveolar Hemorrhage With Nebulized Tranexamic Acid and Recombinant Factor VIIa

Introduction: Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication seen in patients with autoimmune disorders or immunocompromised hosts. There is a lack of evidence on optimum hemostatic agents to guide DAH management. A potential treatment option is nebulized tranexamic acid (n-TXA) and nebulized recombinant factor VIIa (n-rFVIIa).

Description: A 48-year-old male was transferred from an outside facility following 2 weeks of hemoptysis and arthralgia. Work-up was concerning for granulomatosis with polyangiitis that was initially managed with pulse dose steroids, rituximab, and cyclophosphamide. In the setting of respiratory failure requiring mechanical ventilation, decreasing hemoglobin, and worsening hemoptysis, DAH was suspected. The decision to initiate nebulized coagulant medications was made starting with TXA 500mg every 6 hours on hospital day 4. Given inadequate response after 4 doses, n-rFVIIa 50mcg/kg every 6 hours was added on hospital day 5.

After dose 3 of n-rFVIIa, oxygen desaturation was noted due to blood clotting in the endotracheal tube (ETT) which resolved with suctioning. As a result, n-rFVIIa was stopped on hospital day 6 and n-TXA was continued. On hospital day 9, improvement in hemoptysis was demonstrated by a decrease of bloody secretions and an increase in arterial oxygen (PaO2)/FiO2 ratio. Complete hemostasis was achieved and n-TXA therapy was stopped on hospital day 12. Subsequent therapy was focused on treating the primary autoimmune process and patient was extubated 2 weeks after n-TXA/rFVIIa therapy and discharged home 1 month later.

Discussion: This is the first written case report that demonstrated a complication of n-TXA plus n-rFVIIa in the management of DAH. Hemoptysis resolution was achieved on hospital day 12 after 8 days of n-TXA therapy. However, the addition of n-rFVIIa resulted in blood clotting in the ETT, leading to discontinuation after 3 doses. More literature is needed to advise on the role of combination n-TXA and n-FVIIa to balance safety and risk of localized blood clotting in DAH management.