Tranexamic acid may reduce transfusion risk after TJA

Tranexamic acid has been shown to be cost effective and beneficial in reducing the risk of transfusion after total joint arthroplasty, according to a presenter.

Perspective from Michael B. Cross, MD

“It is interesting when you look back at your historical transfusion risk. We were around 13% prior to tranexamic acid and the year following that we were down to 2% to 3% and we did not do anything other than use tranexamic,” Steven J. MacDonald, MD, said in his presentation.

Systematic reviews, meta-analyses and randomized clinical trials have shown that tranexamic acid (TXA) is effective in reducing the risk of blood loss during TJA, MacDonald said. TXA can be used intravenously in patients at high risk for transfusion if they have not received a stent in the past 3 months, he said.

“All of the trials show that [tranexamic acid] favors decreased transfusion and they also show there is not an increased risk of thrombosis,” MacDonald said.

TXA can be cost-effective, he said.

MacDonald reported a transfusion in Canadian dollars (CAD) cost $400 compared with $20 CAD for an average dose of TXA. Although TXA can be given intravenously, by injection or orally, oral application may be the most cost-efficient, he noted.

An IV dose of TXA is based on the patient’s weight, according to MacDonald. It is used immediately prior to incision in total hip arthroplasty and a few minutes before releasing the tourniquet in total knee arthroplasty.

Among patients undergoing revision TKA, there was a reduction in transfusion by 47%, 40% and 71% in infected cases undergoing stage I revision, stage II revision and a standard revision, respectively, he said.

“We use it in all our revisions at the same cost effectiveness,” MacDonald said. “At our institution, we have saved around $25,000 (CAD) a year with this simple methodology.” – by Casey Tingle

Reference:

MacDonald SJ. Minimizing blood loss in total joint arthroplasty. Presented at: Orthopedics Today Hawaii 2018; Jan. 7-11, 2018; Koloa, Hawaii.

For more information:

Steven J. MacDonald, MD, FRCS, can be reached at 1151 Richmond St., London, Ontario, Canada, N6A 3K7; email: steven.macdonald@lhsc.on.ca.

Disclosure: MacDonald reports he receives royalties and consulting fees from DePuy Synthes; and has ownership interest in Hip Innovations Technology and JointVue LLC.

Perspective

Michael B. Cross, MD

Strong evidence supports that perioperative use of TXA decreases postoperative blood loss and reduces the need for postoperative transfusions. As a result, the use of TXA is becoming the standard of care in primary and revision TJA.

Although concern remains regarding the risk of prothrombotic adverse events, including deep vein thrombosis, MI, pulmonary embolism and cerebrovascular events with routine use of TXA, the literature has continued to show that use of TXA does not increase the risk of thromboembolic events in TJA.

While exclusion criteria are institution-dependent, common exclusion criteria in the literature include a history of arterial or venous thromboembolic disease (DVT, PE, cerebrovascular event, etc.), allergy to TXA, coronary or vascular stent placement within 6 months of surgery, history of subarachnoid hemorrhage and history of any hypercoagulable disorder. Finally, it appears TXA is beneficial regardless of it being administered via IV, topically or orally. As indicated by MacDonald, oral TXA is the most cost-effective route of administration; however larger, randomized, controlled trials are underway to determine if oral TXA is equivalent in terms of safety and efficacy to IV or topical administration.

Michael B. Cross, MD

Hip and knee surgeon

Hospital for Special Surgery

New York

Disclosures: Cross reports he is on the advisory board and is a consultant for Acelity; is a consultant for Exactech, Flexion Therapeutics, Intellijoint Surgical and Zimmer Biomet; is on the speakers bureau for Flexion Therapeutics; and has ownership interest in Intellijoint Surgical.