Subcutaneous Tranexamic Acid at the End of Life in a Patient With Hereditary Hemorrhagic Telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder characterized by vascular malformations, which cause frequent bleeding events including epistaxis and gastrointestinal bleeding.1 We describe the management of an 84-year-old woman with HHT who received end-of-life care on a palliative care ward. When the patient was unable to swallow her tranexamic acid tablets, this was converted to a continuous subcutaneous infusion, which was continued for a week until death. She had no significant bleeding events or site reactions. To our knowledge, this case report is the first to describe the palliative management of a patient with HHT at the end of life. This also adds to the current evidence base that subcutaneous tranexamic acid may be a safe and effective alternative to oral administration. Further research is needed to improve understanding of the appropriate patient selection, safety, and efficacy.

Use of long term aprepitant as a treatment for refractory nausea following oesophageal stent insertion - a case report.

BACKGROUND: Aprepitant, a substance P neurokinin-1 receptor antagonist, is licenced for the prevention of acute and delayed nausea and vomiting associated with highly and moderately emetogenic cancer chemotherapy. CASE: A 33 year-old male with metastatic gastro-oesophageal cancer had multiple admissions for refractory nausea and vomiting following insertion of an oesophageal stent. ACTION: Mechanical issues with the stent, stent removal and central causes were excluded. Multiple anti-emetic agents were trialled in combination and with varying routes of administration without significant symptomatic improvement. FORMULATION: A trial of aprepitant was proposed as an off-licence therapy. OUTCOME: One hundred sixty-five milligrammes of aprepitant was given orally every 3 days and then up titrated to once daily with significant symptomatic improvement enabling the patient to tolerate an oral diet. The patient remained stable at 12 weeks and has been accepted into two clinical trials for potential further cancer treatment. LESSONS: Aprepitant can be effective in refractory nausea and vomiting outside of emetogenic chemotherapy and safely used as a chronic treatment. The prevalence of refractory nausea and vomiting as a rare adverse outcome post-oesophageal stent insertion should be studied. WHAT NOW?: Further research of neurokinin-1 inhibitors for indications other than chemotherapy-induced nausea and vomiting is indicated.