Table.

Prophylactic Protocol for Managing a Contact-Sport Athlete With Hemophilia

1. The athlete cannot have a history of spontaneous bleeds and playing cannot cause bleeding into the knees or ankles.

2. No intramuscular injections of any kind are given.

3. The athlete's management must be discussed with the school's insurance company to ensure coverage of any sport-related injury. Typically, coverage excludes direct hemophilia-related medications or treatment.

4. The athlete or guardian (if the athlete is a minor) must sign a preexisting-condition medical-release agreement that contains standard wording for release of liability, acknowledgment of the awareness of risk by the athlete, and awareness of the possibility that the insurance company may not cover some expenses.

5. Clinicians should know the untreated factor VIII level and factor VIII inhibitor status of the athlete. These data are used by the athlete's hematologist to determine the prophylaxis dose and track the response to treatment.

6. With the help of the athlete's hematologist, the clinician should chart the recombinant antihemophilic factor (eg, Kogenate, RECOMBINATE [Baxalta US Inc, Bannockburn, IL], ADVATE [Baxalta US Inc], Bioclate [Cerner Multum, Inc, Denver, CO], ELOCTATE [Biogen, Cambridge, MA]) prophylaxis schedule. A typical schedule is 25–30 mg/kg 3 times/wk (eg, Monday, Wednesday, Friday) with an additional 40 mg/kg before games: the physician usually selects a single dose from among the available dosages, so that mixing is not necessary.

7. The prophylactic dose is given 1–2 hours before a game. If a dose is scheduled for a practice day, the medication is given 1–2 hours before the practice.

8. All injections are given in presence of the athletic trainer (or team physician if available) to ensure compliance.

9. For travel to away games, the athlete should bring 6 doses of factor VIII because hospitals usually do not have recombinant factor VIII readily available. Light and heat are detrimental to the medication, so it should be kept at a maximum of room temperature and preferably in a cooler (but not frozen). The athletic trainer stows the medication in his or her carry-on luggage to avoid loss.

10. The athlete cannot play at away games unless a hemophilia treatment center is within 75 miles.

11. Injuries are treated with factor VIII administration. The RICE protocol (rest, ice, compression, elevation) is also important, although it does not take the place of factor VIII.

Dosages should be confirmed with the athlete's hematologist in advance:

Serious injury: 40 mg/kg as soon as possible and daily until bleeding is resolved (generally 3 days).

Joint hemarthrosis: 40 mg/kg twice per day for 3–4 days.

Head injury: 40 mg/kg as soon as possible and computed tomography imaging of the head.