Bleeding, recurrent

XIII Umbilical cord, intracranial, and joint bleeding recurrent miscarriages, impaired wound healing Normal PT, aPTT, thrombin time, bleeding time Specific factor XIII assay... 

These drug are used cautiously in patients with renal or hepatic disease, bladder obstruction, seizure disorders, sick sinus syndrome, gastrointestinal bleeding, and asthma Individuals with a history of ulcer disease may have a recurrence of the bleeding. 

NSAIDs can induce a number of other adverse reactions, including bleeding disorders, anemia, thrombocytopenia, erythema nodosum, erythema multiforme, fixed drug eruptions, toxic epidermal necrolysis, Stevens-Johnson syndrome, leukocytocla-sitc vasculitis, recurrent fever with exanthema and, of course, the well-known gastric cytotoxicity. 

The abciximab in Acute Ischemic Stroke trial was a randomized, placebo-controlled dose-escalation study to examine the safety of abciximab in acute stroke. It randomized 74 patients within 24 hours of stroke onset to receive one of four doses of abciximab (by bolus with or without additional infusion, 54 patients) or placebo (20 patients). The median baseline National Institute of Health Stroke Scale (NIHSS) score was 15. The rates of asymptomatic ICH were 19% in the intervention group compared to 5% in the placebo group p = 0.07). Most (9 of 11) of the asymptomatic ICH patients had more severe stroke (NIHSS >14). No cases of symptomatic ICH or major systemic bleeding occurred. There was a trend toward a lower rate of stroke recurrence (2% vs. 5%) and a higher rate of functional recovery at 3 months in the group treated with abciximab than with placebo. 

In patients who experience a PUD-related bleeding event while taking aspirin but who require continued aspirin therapy, the addition of a PPI reduces the incidence of recurrent GI bleeding.27... 

Selective COX-2 inhibitors are not superior to PPIs in preventing NSAID-related PUD. One randomized, place-bo-controlled trial that included 267 patients at high risk for ulceration (arthritic patients with a previously healed bleeding ulcer) compared celecoxib 200 mg twice daily to the combination of diclofenac 75 mg twice daily plus omeprazole 20 mg daily.32 After 6 months, the risk for recurrent bleeding was found to be similar between groups (celecoxib, 4.9% and diclofenac/omeprazole, 6.4%) the authors concluded that neither of these therapies can completely prevent recurrent ulcer complications. 

Chan FK, Hung LC, Suen BY, et al. Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis. N Engl f Med 2002 347 2104-2410. 

Warning signs to report to a physician (recurrent or difficult-to-cure infections, infections with malodorous discharge or bleeding)... 

Nonselective /J-blockers, EBL, or both should be used for prevention of recurrent variceal 1A bleeding... 

Less than one-half of patients develop symptoms of recurrence such as pain syndromes, changes in bowel habits, rectal or vaginal bleeding, pelvic masses, anorexia, and weight loss. CEA levels may help detect recurrences in asymptomatic patients. 

Monitoring Monitor closely with an intact uterus for signs of endometrial cancer evaluate recurrent or persistent abnormal vaginal bleeding appropriately to rule out malignancy. 

Close clinical surveillance of all women taking OCs is essential they should be reexamined at least once a year. In all cases of undiagnosed persistent or recurrent abnormal vaginal bleeding, rule out malignancy. Monitor women with a strong family history of breast cancer or who have breast nodules, fibrocystic disease of the breast, cervical dysplasia, or abnormal mammograms. 

Wustrow TP, Behbehani AA, Wiebecks B. 1988. Thorotrast-induced oro- and hypopharyngeal fibrosis with recurrent bleeding. J.Cranio-Maxillo-Facial Surg 16 315-319. 

Unlabeled Uses Prevention of aspiration pneumonia, treatment of recurrent postoperative ulcer, upper GI bleeding, prevention of acid aspiration pneumonitis during surgery, prevention of stress-induced ulcers. 

Unlabeled Uses Prevention and treatment of discoid lupus erythematosus, erythema multiforme, graft vs host reactions following bone marrow transplantation, rheumatoid arthritis treatment of Behget s syndrome, Crohn s disease, G1 bleeding, multiple myeloma, pruritus, recurrent aphthous ulcers in HIV patients, wasting syndrome associated with HIV or cancer... 

G. Other applications Octreotide has been reported to be effective in treating noninfectious diarrhea and diarrhea in patients with AIDS, and as an adjunct to endoscopic variceal ligation, to reduce recurrent bleeding from esophageal varices. Micromedex lists many other potential uses. 

Gastrointestinal ulceration may occur less frequently than with some other NSAIDs. A preparation combining diclofenac and misoprostol decreases upper gastrointestinal ulceration but may result in diarrhea. Another combination of diclofenac and omeprazole was also effective with respect to the prevention of recurrent bleeding, but renal adverse effects were common in high-risk patients. Diclofenac, 150 mg/d, appears to impair renal blood flow and glomerular filtration rate. Elevation of serum aminotransferases occurs more commonly with this drug than with other NSAIDs. 

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