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Routine use of tranexamic acid was effective during primary TJA
The rapid expansion of high-evidence literature in this area highlights the need for clinical practice guidelines on tranexamic acid.
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DALLAS — Supported by a direct and a network meta-analysis, researchers compiled guidelines focused on the use of tranexamic acid during total joint arthroplasty, which were presented at the American Association of Hip and Knee Surgeons Annual Meeting.
Tranexamic acid (TXA) is not FDA approved for use in orthopedics.
“TXA is an effective drug,” Yale A. Fillingham, MD, adult reconstruction fellow at the Rothman Institute, told Orthopedics Today. “It should become standard of care for our arthroplasty patients and I would stress we need to look at the risks of withholding the medication just as much as we look at the risks of giving the medication in subsets of patient populations.”
TXA in arthroplasty cases
In his presentation, Fillingham noted individual use and combinations of TXA are effective compared to placebo, but no one administration method is clearly superior to another. The efficacy of the drug is not significantly affected by the dose of IV or topical TXA at the doses commonly used in arthroplasty.
“Utilizing six high-quality studies for the direct [meta-analysis] and all 88 studies for the network [meta-analysis], we found little evidence to support higher doses of TXA,” Fillingham said in his presentation. “However, it does not preclude the presence of a dose response for TXA, but simply that at the doses we are utilizing in arthroplasty and the amount of blood loss we are experiencing in total joint arthroplasty it is not showing through in the data.”
The meta-analysis showed multiple doses of IV or oral TXA are not superior to a single dose.
According to Fillingham, the research group recommended pre-incision administration of TXA, with moderate strength.
“Despite the inconsistencies in the results, we still recommend pre-incision administration because the results demonstrate no potential benefit for post-incision administration, but in some analyses [done] in total knee arthroplasty studies, they do show that pre-incision administration is better,” he said.
Fillingham noted that patients without a prior history of venous thromboembolism were not at any greater risk of an increased risk of a VTE, and that high-risk patients did not appear to have an increased risk of VTE with the use of TXA. Similarly, TXA use did not appear to increase the risk of arterial thromboembolic events.
“Despite the inclusion of high-quality studies, we were only able to provide moderate support due to the limited number of studies and the lack of studies specifically designed to investigate the risk of arterial events,” Fillingham said.
Need for guidelines
The rapid recent increase in the number of studies about TXA has underscored the need for related clinical practice guidelines, according to Fillingham.
“Everybody has been ... trying to identify what is the optimal formulation, dose, timing of the medication and the number of doses, but nobody has sat down and [done] a thorough review and coalesced all of this massive amount of high-evidence literature that we have on the topic,” he said.
Currently, the TXA guidelines Fillingham and colleagues developed related to TJA are undergoing organizational approval from the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, the Hip Society, the Knee Society and the American Society of Regional Anesthesia and Pain Medicine, he said.
“Once they are reviewed, then we will work toward formally publishing the peer-reviewed document,” Fillingham said. – by Casey Tingle
- Reference:
- Fillingham YA, et al. Paper #3. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 2-5, 2017; Dallas.
- For more information:
- Yale A. Fillingham, MD, can be reached at 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; email: yale.fillingham@gmail.com.
Disclosure: Fillingham reports no relevant financial disclosures.