Choosing Wisely : ®

Things We Do
for No Reason™
Routinely Prescribing Transfusion Premedication To Prevent
Acute Transfusion Reactions

Based on Lim MY, Pagano MB, Metcalf RA. Routinely Prescribing Transfusion
Premedication To Prevent Acute Transfusion Reaction. J Hosp Med. 2020;15(11):684-686.

@JHospMedicine | #TWDFNR
Clinical Scenario
• 68-year-old woman is admitted for fatigue and shortness of breath
on exertion with a hemoglobin of 6.5 g/dL
• Past Medical History: Myelodysplastic syndrome
• Vital signs: Tachycardic with heart rate of 105
• Treatment: First red blood cell (RBC) transfusion
• Hospitalist orders premedication with acetaminophen and
diphenhydramine to prevent acute transfusion reaction

@JHospMedicine | #TWDFNR
Why You Might Think This is Necessary
• The most frequent complications of blood transfusion are
allergic transfusion reactions (ATRs) and febrile
nonhemolytic transfusion reactions (FNHTRs), with a
combined incidence of 1% – 4% per transfusion1
• Perhaps acetaminophen could blunt the febrile response in
FHNTRs
• ATRs, which are caused by recipient histamine release in
response to exposure to donor plasma proteins, could
theoretically be prevented by an antihistamine

@JHospMedicine | #TWDFNR
 Why This Is Not Helpful
• Randomized controlled trials show premedication with acetaminophen and
an antihistamine does not reduce the risk of ATR and FNHTR2-4

Rate of transfusion reaction

Study Population Blood product Intervention
Intervention Placebo P-value

51 with Acetaminophen and

Wang Platelet
hematological diphenhydramine vs 15.40% 15.20% 0.94
(2002) transfusion
malignancies placebo

315 with Acetaminophen and

Kennedy RBC or platelet 1.444 per 100 1.51 per 100
hematological diphenhydramine vs 0.43
(2008) transfusion transfusions transfusions
malignancies placebo

Acetaminophen and
Rujkijyanont 147 with
RBC transfusion chlorpheniramine vs 6.90% 9.50% 0.565
(2018) thalassemia
placebo

@JHospMedicine | #TWDFNR
What You Should Do Instead
• Rather than pretreating the patient, consider modifying the blood product
selected for transfusion
• Prestorage leukoreduction of RBC and platelet components to remove
donor leukocytes reduces incidence of FNHTRs by approximately 50%5
• Plasma volume reduction to decrease coadministration of allergy-inducing
plasma proteins reduces incidence of platelet-associated ATRs by 50%6
• For patients with recurrent severe ATRs, blood banks can wash RBC and
platelet components, removing virtually all plasma proteins7
• Avoid unnecessary transfusions

@JHospMedicine | #TWDFNR
Recommendations
• Do not prescribe an antihistamine or acetaminophen prior to transfusion
• Reduce the risk of FNHTRs in all transfusion recipients with universal
prestorage leukoreduction
• For individuals with multiple recurrent ATRs to platelets, employ platelet
additive solution or platelet volume reduction to reduce the plasma
volume administered
• Reserve washing RBC and platelet components for patients with a history
of severe ATRs
• Make sure epinephrine is at the patient’s bedside
• Curb unnecessary blood transfusions to reduce avoidable transfusion
reactions
• Monitor patients undergoing transfusion closely

@JHospMedicine | #TWDFNR
Conclusions
• No indication for premedication with acetaminophen and/or
antihistamine in this case scenario
• Avoid unnecessary transfusion — if a transfusion does not
occur, then neither will a transfusion reaction

@JHospMedicine | #TWDFNR
References
Based on Lim MY, Pagano MB, Metcalf RA. Routinely Prescribing Transfusion Premedication To Prevent Acute
Transfusion Reaction. J Hosp Med. 2020;15(11):684-686.

1.Fung MK, Eder A, Spitalnik SL, Westhoff CM. American Association of Blood Banks Technical Manual. 19th Ed: Bethesda, Md: AABB; 2017.
2.Acetaminophen and diphenhydramine as premedication for platelet transfusions: a prospective randomized double-blind placebo-controlled
trial. Am J Hematol. 2002;70(3):191-194.
3.A prospective, randomized, double-blind controlled trial of acetaminophen and diphenhydramine pretransfusion medication versus placebo
for the prevention of transfusion reactions. Transfusion. 2008;48(11):2285-2291.
4.Efficacy of oral acetaminophen and intravenous chlorpheniramine maleate versus placebo to prevent red cell transfusion reactions in
children and adolescent with thalassemia: a prospective, randomized, double-blind controlled trial. Anemia. 2018;2018:9492303.
5.Universal leukoreduction decreases the incidence of febrile nonhemolytic transfusion reactions to RBCs. Transfusion. 2004;44(1):25-29.
6.Evaluating safety and cost-effectiveness of platelets stored in additive solution (PAS-F) as a hemolysis risk mitigation strategy. Transfusion.
2019;59(4):1246-1251.
7.Prevention of allergic transfusion reactions to platelets and red blood cells through plasma reduction. Transfusion. 2011;51(8):1676-1683.

@JHospMedicine | #TWDFNR
Citation
To cite this teaching tool:

Lim MY; Metcalf RA. Routinely Prescribing Transfusion Premedication To Prevent

Acute Transfusion Reaction. Tool published at
https://www.journalofhospitalmedicine.com/jhospmed/article/217191/hospital-
medicine/things-we-do-no-reasontm-routinely-prescribing-transfusion?
channel=27621 Accessed December 28, 2020

@JHospMedicine | #TWDFNR
@JHospMedicine | #TWDFNR