Priority 14 from the Blood Transfusion and Blood Donation PSP

UNCERTAINTY: Are drugs* a cost effective alternative to blood transfusion for the management of anaemia? *Drug alternatives are medicines that can be used in place of a blood transfusion, for example drugs such as iron and recombinant erythropoietin for the treatment of anaemia. (JLA PSP Priority 14)
Overall ranking 14
JLA question ID 0063/14
Explanatory note Not available for this PSP


  1. NICE Guideline Recommendations 1-5: Alternatives to blood transfusion for patients having surgery: Oral iron, IV iron and erythropoietin
    1. Do not offer erythropoietin to reduce the need for blood transfusion in patients having surgery, unless:
      • the patient has anaemia and meets the criteria for blood transfusion, but declines it because of religious beliefs or other reasons or
      • the appropriate blood type is not available because of the patient’s red cell antibodies.
    2. Offer oral iron before and after surgery to patients with iron-deficiency anaemia.
    3. Consider intravenous iron before or after surgery for patients who:
      • have iron-deficiency anaemia and cannot tolerate or absorb oral iron, or are unable to adhere to oral iron treatment (see the NICE guideline on medicines adherence)
      • are diagnosed with functional iron deficiency
      • are diagnosed with iron-deficiency anaemia, and the interval between the diagnosis of anaemia and surgery is predicted to be too short for oral iron to be effective.
    4. For guidance on managing anaemia in patients with chronic kidney disease, see the NICE guideline on anaemia management in chronic kidney disease.
    5. For guidance on managing blood transfusions for people with acute upper gastrointestinal bleeding, see section 1.2 in the NICE guideline on acute upper gastrointestinal bleeding.
  2. NICE Guideline Recommendations 6-9: Alternatives to blood transfusion for patients having surgery: Cell salvage and tranexamic acid
    • 6. Offer tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml)
    • 7. Consider tranexamic acid for children undergoing surgery who are expected to have at least moderate blood loss (greater than 10% blood volume).
    • 8. Do not routinely use cell salvage without tranexamic acid.
    • 9. Consider intra-operative cell salvage with tranexamic acid for patients who are expected to lose a very high volume of blood (for example in cardiac and complex vascular surgery, major obstetric procedures, and pelvic reconstruction and scoliosis surgery).
  3. Li C, Gong Y, Dong L, Xie B, Dai Z. Is prophylactic tranexamic acid administration effective and safe for postpartum hemorrhage prevention? A systematic review and meta-analysis. Medicine. 2017;96(-1):e5653-e.
  4. Ray S, Ray A. Non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders. The Cochrane Database of Systematic Reviews. 2016(-11):CD010338-CD.
  5. Prutsky G, Domecq JP, Salazar CA, Accinelli R. Antifibrinolytic therapy to reduce haemoptysis from any cause. The Cochrane Database of Systematic Reviews. 2016(-11):CD008711-CD.
  6. Jiang M, Chen P, Gao Q. Systematic review and network meta-analysis of upper gastrointestinal hemorrhage interventions. Cellular Physiology and Biochemistry : International Journal of Experimental Cellular Physiology, Biochemistry, and Pharmacology. 2016;39(-6):2477-91.
  7. Roberts I, Shakur H, Ker K, Coats T, collaborators C-T. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database of Systematic Reviews. 2015;5:CD004896-CD.
  8. Marti-Carvajal AJ, Sola I. Antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease. Cochrane Database of Systematic Reviews. 2015(-6):CD006007-CD.  
  9. Alam A, Choi S. Prophylactic use of tranexamic acid for postpartum bleeding outcomes: a systematic review and meta-analysis of randomized controlled trials. Transfusion Medicine Reviews. 2015;29(-4):231-41.
Health Research Classification System category Generic Health Relevance
Extra information provided by this PSP
Original uncertainty examples What alternatives provide the best outcome? ~ What happens when an individual cannot receive transfusion due to reaction? ~ What happens when an individual cannot receive transfusion due to reaction?  ~ The effectiveness and cost-effectiveness of erythropoiesis-stimulating agents (epoetin and darbepoetin) for treating cancer treatment-induced anaemia: It may also be helpful to explore reasons why improved anaemia may lead to better outcomes; that is, whether ESAs allow better compliance with chemotherapy.
Submitted by 2 blood recipients ~ 5 relatives or carers of blood recipients ~ 8 blood donors ~ 14 health professionals ~ 4 unknown ~ 9 other (questions not from survey)
PSP information
PSP unique ID 0063
PSP name Blood Transfusion and Blood Donation
Total number of uncertainties identified by this PSP 51  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 28 February 2018