The identification of high-risk elbow hemorrhages in adolescents with severe hemophilia A

THE CORNERSTONE of the management of bleeding episodes in hemophiliac patients without inhibitors to Factor VIII is early and adequate replacement therapy with Factor VIII-containing materials. The treatment of established hemorrhages with an average dose of 15 units/kg results in a retransfusion rate of 15% within 24 hours? The advent of home therapy has increased the promptness of treatment and allowed smaller doses of Factor VIII to be used. However, even this early treatment does not abort more than 85% of hemorrhages? These persistent hemorrhages are likely to be associated with the continued presence of blood in the joint, maintaining the synovial cellular reaction.:' This leads to a hypertrophied synovium, with the hypervascularity and hyperemia of the inflammatory response becoming the seat of further and repeated hemorrhages? Bleeding frequency is thus likely to increase in the short term, and some hemophiliac patients will progress to end-stage arthropathy in spite of receiving adequate and prompt treatment." Allain ~ has shown that an initial dose of 26 units/kg of Factor VIII is needed to abort all hemorrhages. Such a regimen would cause severe problems of supply and may well be deemed unsuitable in view of the problems which beset the multitransfused hemophiliac/The identification of those hemorrhages likely to do badly, and the selective application of a high dose may reduce the requirements for retransfusion with consequent reduction in bleeding, arthropathy, and overall consumption of Factor VIII. The elbow joints suffer a steadily increasing incidence of hemorrhages through adolescence, are the most frequent site of bleeding , and account for over 25% of all episodes by the age of 15 years? The identification of high-risk hemorrhages in the elbow joint in early adolescence is thus likely to be an important first step toward the elimination of chronic hemophilic arthropathy developing in late adolescence. We have reviewed 144 elbow hemorrhages treated with an initial dose of 11 to 16 units of Factor VIII per kilogram at this institution during the past year in an