Acquired Inhibitors: A Special Case of Bleeding in Older Adults

This literature review is intended to familiarize physicians and healthcare providers of older adults with the potential causes of acute bleeding in older adults and to review diagnostic approaches that can produce prompt identification of acute bleeding and facilitate timely treatment. Adverse events from anticoagulant treatment and nonsteroidal anti-inflammatory drug (NSAID) and aspirin use and abuse are among the most common causes of bleeding in older adults. Diagnoses infrequently considered—mild congenital hemophilia, acquired hemophilia, von Willebrand disease, and platelet dysfunction—can contribute to acute bleeding in older adults. The approach to management of bleeding varies. Management of acute bleeding in older adults can be challenging because these patients often have chronic comorbidity and have been prescribed long-term concomitant medications that can complicate diagnosis and treatment. Prompt recognition of acquired hemophilia, referral to an expert hematologist, and timely initiation of treatment could improve outcome in older patients who experience bleeding episodes resulting from this condition. 1. Introduction The diagnosis of acute bleeding in older adults is challenging because the presence of chronic comorbidities and polypharmacy not only places these individuals at increased risk for bleeding, but also complicates the identification of underlying causes [1, 2]. While adverse events from anticoagulant treatment and nonsteroidal anti-inflammatory drug (NSAID) and aspirin use and abuse are among the most common causes of bleeding in older adults [3–9], other less frequent etiologies should not be overlooked [1, 2]. Diagnoses not often considered—such as previously undiagnosed mild congenital hemophilia, acquired hemophilia, von Willebrand disease, and platelet dysfunctions associated with uremia and liver cirrhosis—can all contribute to acute bleeding in older adults. Acquired factor VIII inhibitors (acquired hemophilia) are a rare but potentially life-threatening cause of acute bleeding in older adults [10–12], with fatal bleeding occurring in an estimated 21% of patients [12]. Because of its rarity, acquired hemophilia is often not considered in the differential diagnosis. This failure to recognize acquired hemophilia often results in delayed initiation of appropriate treatment, and misdiagnosis, with initiation of potentially harmful procedures and/or treatments, can negatively affect patient outcome [13–15]. Surgery in patients with acquired hemophilia can be particularly problematic [15], especially when performed without