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A. The national blood transfusion service in the UK collects around 2.5 million blood donations a year from 1.7 million registered donors. The NHS needs 7,000 voluntary donations of blood daily but only around 4 per cent of the eligible population are active donors. The need for more new and regular donors is, therefore, an ongoing priority. Types of transfusion and examples of their uses are given in Panel 1.
Panel 1: Types of blood transfusion
Red blood cell Red blood cell transfusions are most common. They are mainly used to treat anaemia (eg, in patients who lack iron, patients with severe blood loss, such as in injury or childbirth, patients with thalassaemia or sickle cell, and in some cases of malaria).
Platelet A platelet transfusion is used to treat thrombocytopenia (eg, in patients with leukaemia or cirrhosis and in those receiving chemotherapy).
Plasma Plasma may be needed in cases of severe bleeding (eg, after surgery, trauma or childbirth) to help clotting. It may also be needed in liver disease where the production of clotting factors is affected.
Granulocyte Granulocyte transfusions are uncommon. They may be used for severe neutropenia following failed antibiotic therapy, after chemotherapy or bone marrow transplantation.
Recent changes in UK donor guidelines discontinued the upper age limit of 65 years for existing donors. Healthy men can now donate up to four times a year (at not less than 12-week intervals) and healthy women up to three times a year (at not less than 16-weekly intervals). A minimum weight of 50kg is required.
Harm reduction
The procedures surrounding whole blood donation and transfusion are detailed in “Guidelines for the blood transfusion services in the UK (The Red Book)”.¹ Safety and harm reduction are ensured in three ways. The first is by adherence to the evidence-based criteria set out in the guidelines, which give specifications for all materials used and produced by the transfusion service.
The second is the initial completion, at donation sessions, of a comprehensive questionnaire by prospective donors, relating to their health, lifestyle, travel history, past medical and sexual history and any concurrent medication. Capillary blood is also tested to ensure that male and female donors have minimum haemoglobin values (135 and 125g/L, respectively) and all donors are asked to report any illness that develops within 14 days of donation.
The third safety measure is post-donation laboratory testing for blood groups, syphilis and blood borne viruses (including HIV, hepatitis B and C and human T lymphotropic virus). Additional tests may be undertaken in individual cases for malaria, Trypanosoma cruzi, West Nile virus and cytomegalovirus. Although this expensive and laborious undertaking is a big step forward in recipient safety, a problem still exists with newly acquired infections where neither symptoms nor seropositivity have emerged. The questionnaire described above should address this issue.
Problem drugs
Detailed knowledge among front-line health care workers of how medication may affect blood donation is sparse and there is little guidance in popular therapeutic publications. For example, only three examples appear in the 2012 Electronic Medicines Compendium³ and the current BNF: the oral retinoids acitretin, alitretinoin and isotretinoin. This may seem extraordinary when so many summaries of product characteristics list potentially toxic and life-threatening effects.
Pregnant women are a key group for blood transfusions, and teratogenicity is a possibility if blood containing retinoids were to be given to these recipients. Donation is not allowed if a person has ever taken etretinate (Tigason — no longer in use) or has taken acitretin (Neotigason) in the past 24 months or alitretinoin (Toctino) or isotretinoin (Roaccutane) in the past four weeks. (There are no published data that topical retinoids cause birth defects.) For the same reason, patients taking carbimazole or propylthiouracil may not donate blood. If treatment is stopped, 24 months must elapse before a donation.
Patients taking antiandrogens are also not permitted to donate. Blood containing finasteride or dutasteride can cause abnormal development of the genitalia of male fetuses if given to pregnant women. A donation must not be made if finasteride has been taken in the past four weeks or dutasteride in the past six months.
Blood from donors currently taking non-steroidal anti-inflammatory drugs or antiplatelet medicines cannot be used for preparing platelet packs (see Panel 1) because of their platelet inhibitory effects. Aspirin and piroxicam require a five-day interval between use and donation and other NSAIDs require 48 hours. These agents do not affect donations for red blood cell transfusions, although donations may be refused if the medication is for a serious long-term condition.
Any individual who has ever injected illicit drugs (including anabolic steroids) may not donate because of the long latent period before some blood-borne viruses, such as HIV, can be detected.
Medicines as indicators
General opinion is that, in most cases, plasma concentrations of drugs in donated blood are not sufficiently high to cause harm to recipients. Normally of greater concern is any underlying illness in patients and, of course, medicines are a useful indication of this. Illness can make giving blood a risk to the donor as well as posing a risk for recipients. For example, if a patient is taking a proton pump inhibitor, he or she may have a peptic ulcer, and this would rule out donation (see Panel 2). And if a patient is using asthma inhalers or products for eczema, caution is also required. These and further examples of conditions that pose potential risks are explained further in Panel 2.
Panel 2: Conditions with cautions for blood donation
Asthma Donation is refused if a person is symptomatic: taking blood from a person with asthma symptoms may lower the total arterial oxygen carrying capacity and could worsen the condition. An individual taking regular preventive treatment can be accepted but several recent reports have revealed cases of adrenal suppression with chronic high-dose inhaled steroids, particularly fluticasone 1,000?g daily or more. Adrenal dysfunction can present risks of hypotension as well as adrenal crisis. If it is suspected, waiting 12 months from the last high dose is recommended to allow the adrenal glands to recover.
Cardiovascular disease Donations cannot be accepted from patients on anticoagulant therapy or who have been treated for recurrent thrombosis (two or more episodes) because post donation bleeding or bruising is more likely. After seven days, the blood clotting mechanism should return to normal and where treatment was for an isolated deep vein thrombosis or pulmonary embolism a donation may be accepted provided a specific cause — not of itself a reason for refusal — has been identified. Care is needed with patients with cardiovascular disease in case their condition is exacerbated.
Epilepsy Anyone on anticonvulsant therapy or who has had a fit in the past three years is not allowed to donate. Faints following donation can lead to epileptiform convulsions, secondary to cerebral hypoxia. This could cause difficulties with the Driver and Vehicle Licensing Agency and employers for people who have been free from fits for some time.
Mental health problems Individuals who are over-anxious, depressed, manic or psychotic may not be able to give valid consent. Providing individuals are on stable medication and their condition is controlled, they may donate regardless of the type of psychotropic agents being taken.
Peptic ulceration People with recent symptoms of peptic ulceration or who are on current ulcer healing treatment cannot donate. Bleeding is a common problem associated with peptic ulcers. This can be profuse, requiring transfusion, or gradual, leading to iron deficiency (a 500ml whole blood donation contains about 250mg of iron). Taking blood will reduce ability to compensate for any pathological blood loss and may lead to treatment that would not otherwise have been needed. Any suspicion of malignancy would also prohibit donation.
Skin problems If the venepuncture site is affected by cutaneous lesions, donation should be delayed until it is clear. Severe or infected lesions else where or generalised lesions will delay donation because of the risk of bacteraemia and organisms multiplying quickly to dangerous levels during blood storage.
Thyroid disease Patients with thyroid disease may not donate if the condition is under investigation or if malignancy is suspected. Anyone on maintenance therapy with levothyroxine must be stabilised for at least three months before donation. An over- or an underactive thyroid increases the risk of heart disease. Patients who have had radioactive iodine therapy must wait at least six months before giving blood. (See also main text regarding carbimazole.)
Vaginal candidiasis As a precaution, a minimum of seven days is required after completion of systemic therapy for vaginal candidiasis although treatment with antifungal cream or pessaries would not preclude donation. An infection that returns quickly after treatment may suggest immunosuppression and donations should not be accepted until immunodeficiency is excluded.
An important prerequisite for blood donation is that the donor should be fit and well on the day of donation and that any medical condition should be under control. Blood from a donor with an infection can be dangerous for the recipient. As a precaution, at least seven days must have passed since any systemic antibiotic, antifungal or antiviral therapy before a donation can be made. Similarly, dental patients must wait for at least seven days after tooth extraction, root canal treatment, dental capping or implantation before giving blood because of the risk of bacteraemia. (Fillings or a scale and polish only require a 24-hour wait.)
Caution is also required with donors taking drugs that may mask the signs of infection and inflammation (eg, glucocorticoids, immunosuppressants and some antibiotics). A donation will be permitted if a course of oral or injected steroids has been completed more than seven days ago. Donations should not be taken for at least 12 months after treatment with methotrexate, ciclosporin or phototherapy has finished.
This patient
The answer to this patient’s question would depend on what medicines he is taking and why. As long as he is not taking any of the problem medicines discussed and his medical condition is acceptable, his donation will not be refused.
It may be worth checking if he is currently undergoing any medical investigations, and if he has been referred for a specialist opinion or is on a hospital waiting list, because donation may need to be deferred unless the condition or suspected condition would not be a contraindication to donation.
Donors taking part in clinical trials of drugs cannot be accepted until their involvement in the trial has finished, or the designated clinical support team member has examined the trial protocol and agreed that donors participating in that trial can be accepted. This ruling applies to healthy volunteers (as in phase I clinical trials) as well as patients.
Further reading
The “Whole blood and component donor selection guidelines” is a 196-page document that gives valuable, detailed and comprehensive information on personal, medical and pharmacological criteria determining donor eligibility. The index contains around 970 entries for medical conditions and 290 for drugs. Immunisations are also covered. It should allow healthcare professionals to give advice in most circumstances.
Key points
- In most cases, plasma concentrations of medicines in donated blood are not sufficiently high to cause harm to recipients. However, donations may not be made by people taking oral retinoids, carbimazole, propylthiouracil, dutasteride or finasteride.
- Certain conditions, such peptic ulceration, can make blood donation a risk for the donor.
- The NHS needs 7,000 voluntary donations of blood daily. Many patients with conditions that are well controlled are able to give blood safely.
References
- Guidelines for the Blood Transfusion Services in the UK (7th edition, October 2005). http://www.transfusionguidelines.org.uk/
- Statutory Instrument 2005 No. 50. The Blood Safety and Quality Regulations 2005. ISBN 0 11 051622 2 available at http://www.legislation.gov.uk/
- Electronic Medicines Compendium, 2012 (Datapharm). http://www.medicines.org.uk/
- The Whole Blood and Component Donor Selection Guidelines, Edition 203; Release 16, February, 2013. http://www.transfusionguidelines.org.uk/docs/pdfs/dsg_wb_203_16_01.pdf
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