Emerging solutions and medications offer perspectives for better blood management and transfusion

Alcimed, a consulting company specializing in innovation and the development of new markets, examines the challenges facing blood transfusion worldwide and outlines current and future alternatives that can improve blood management around the world.

Lyon, September 8, 2017 – Every year about two million people in Europe receive blood transfusions to treat an anemic condition characterized by a lack of red blood cells. The condition, a possible result of severe bleeding caused by a road accident or surgery, can lead to death if not properly managed.

Historically, blood transfusion has been the major therapeutic approach to reducing this condition. This procedure is designed to intravenously transfuse blood or a derivative such as red blood cells, plasma or platelets into the patient’s circulatory system.

The rigorous control of donations and adverse events has reduced the risks associated with transfusion to an extremely low level. However, allogeneic transfusion is not a trivial matter and there are still too few donors, which leads to the exploration of possible alternative solutions and the balancing of the use of different options according to the patient’s situation.

Blood management policies

With this in mind and to address the chronic shortage of available blood, WHO[1] and its Member States have adopted measures to rationalize the use of allogeneic transfusions while improving patient care. These measures include strengthening anemia and coagulation management, for example by diagnosing and treating anemia prior to surgical procedures. Reducing blood loss by developing less invasive surgical practices has also helped avoid allogeneic transfusion in a number of cases.

Some countries have taken the lead in advancing patient blood management. Early on, the United Kingdom set up working groups (Joint United Kingdom, AAGBI, NIHBT, NICE), investing in drafting recommendations for the use of blood products and contributing to the continuous improvement of medical practices. The National Blood Authority in Australia facilitates the implementation of patient blood management measures at the national level through staff training and hospital assessments.

The implementation of policies to rationalize transfusions has demonstrated their medico-economic effectiveness. In the Netherlands, the rationalization of transfusions since 2007 has reduced the number of unnecessary blood transfusions[2] by 26%. In the United States, where the price of a red blood cell bag is $1,200, studies have shown the impact of such practices on hospital finances. For instance, in a 500-bed hospital transfusing 4,000 units of red blood cells per year, such practices can save more than $1,000,000 per year through reducing transfusions by 25%.

Autotransfusion and hemostatic agents

The most common alternatives and complementary solutions to allogeneic transfusion for global blood management are autotransfusions and hemostatic agents. The principle of autotransfusion is to collect the patient’s blood before, during or after the operation, purify it and concentrate it for re-transfusion when the surgeon considers that a blood bag is necessary. The second solution is to use two kinds of molecules with distinct actions on the patient: stimulating blood production or facilitating coagulation and limiting its loss (hemostatic agents).

These two solutions both have their advantages and the approach chosen currently depends on the country, the hospital and especially the surgeon and their habits or training.

Medically, hemostatic agents are very simple to use and there are several years of clinical data demonstrating the strength of the approach. However, it may cause allergies and is contraindicated in cases of arterial and venous thromboembolic diseases (stroke, pulmonary embolism, etc.) and in patients with a history of convulsions.

Autologous transfusion guarantees the integrity of the blood as well as the absence of any toxins and is mainly used in Germany and the United Kingdom. This approach is currently experiencing a favorable dynamic with the removal of contraindications to its use for certain surgeries. The United Kingdom has recently published recommendations[3] with a favorable positioning on the use of autotransfusion for pediatric and cancer-related surgeries. Until now, there has been a precautionary contraindication in those conditions, as no valid medical study has evaluated the potential of this technology in those situations.

From a medico-economic point of view, hemostatic agents are the most cost-effective: €200 compared to €320 for allogeneic blood[4]. According to the same source, autologous transfusion is in second place, at €250 per operation. This lower cost represents significant sums for the most advanced hospitals, which may have as many as 5 uses of autotransfusion devices per day.

What future for blood management?

While these new approaches complement the solutions available to physicians for treating anemia, they cannot completely replace allogeneic transfusion, which remains the most appropriate solution in a number of situations.

But they will continue to grow. A publication of European recommendations (Good Practices in the Field of Blood Transfusion) by the working group appointed by the CHaFEA[5] agency is expected and Germany hopes to expand the use of autotransfusion at the national level within 5 to 10 years.

Despite promising beginnings, practitioners’ habits are difficult to change with mere legislation. The innovation requires training and practice to be persuasive and to be integrated into current practices. Systematic training during medical studies would be a real stepping stone. Moreover, demonstrating the medico-economic effectiveness of these approaches to funders – politicians or hospital management – is also key to making them a new standard of care to enable allogeneic transfusion to be used only in cases of extreme necessity.

[1] Directive WHA63.12 from 2010

[2] Transfusions which retrospectively looking brought no benefit to the patient

[3] AAGBI guidelines: the use of blood components and their alternatives 2016

[4] Tomeczkowski et al, Potential cost saving of Epoetin alfa in elective hip or knee surgery due to reduction in blood transfusions and their side effects: a discrete-event simulation model, Plos One (2013)

[5] Consumers, Health and Food Executive Agency