Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety

Poeran, Jashvant; Rasul, Rehana; Suzuki, Suzuko; Danninger, Thomas; Mazumdar, Madhu; Opperer, Mathias; Boettner, Friedrich; Memtsoudis, Stavros G.

doi:10.1136/bmj.g4829

Cited by 387 publications

(320 citation statements)

References 28 publications

(38 reference statements)

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“…13 This was mirrored by our relatively low provincial and institutional use of TXA at the time of protocol implementation. The discrepancy between the available data for efficacy of TXA therapy and our actual practice of administering TXA suggested that a translational gap existed at our institution.…”

Section: Discussionmentioning

confidence: 99%

“…Recent observational studies have also shown an association between TXA use and reduced RBC transfusion. 12,13 Despite this clear affirmation of efficacy by numerous randomized trials, concerns about associated adverse outcomes and safety have not been adequately addressed largely due to the uniformly small sample size of these studies. This concern was cited as one of the main reasons for the strikingly low percent utilization of TXA (11.2%) in the United States.…”

Section: Résumémentioning

confidence: 99%

“…This concern was cited as one of the main reasons for the strikingly low percent utilization of TXA (11.2%) in the United States. 13 Despite the amount of supportive literature in favour of TXA utilization, a recent review from the Ontario Transfusion Coordinators (ONTraC) database revealed that 50.8% of patients undergoing primary hip or knee arthroplasty received TXA in 2013 (personal communication Dr. John Freedman). Review of our institutional practice revealed that our TXA utilization (45.8%) was low relative to other ONTraC centres.…”

Section: Résumémentioning

confidence: 99%

See 2 more Smart Citations

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

Baker

Pavenski

Pirani

et al. 2015

Can J Anesth/J Can Anesth

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Section: Discussionmentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

See 1 more Smart Citation

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

Baker

Pavenski

Pirani

et al. 2015

Can J Anesth/J Can Anesth

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“…A recent large retrospective cohort study drawn from administrative health data may have put some of these concerns to rest. 4 In this study of 872,416 patients who had total hip or knee arthroplasty, multilevel multivariable logistic regression modelling was used to assess the association between intravenous use of TXA and patient outcome. Tranexamic acid was given to 20,051 patients, and results at the end of the seven-year study period showed that the proportion of patients receiving TXA increased from almost 0% to 11.2%.…”

mentioning

confidence: 99%

“…Une grande étude récente de cohorte rétrospective extraite des données administratives de santé a peut-être permis de répondre à ces préoccupations. 4 Dans cette étude de 872 416 patients ayant subi une arthroplastie totale de genou ou de hanche, un modèle de régression logistique multifactorielle à plusieurs niveaux a été utilisé pour évaluer l'association entre l'administration intraveineuse de TXA et l'évolution des patients. L'acide tranexamique a été administré à 20 051 patients et les résultats au terme de la période d'étude de 7 ans ont montré que le pourcentage de patients recevant du TXA est passé de presque 0 % à 11,2 %.…”

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Tranexamic acid: When is enough (data) enough?

Ralley

2015

Can J Anesth/J Can Anesth

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Tranexamic acid (TXA) is a synthetic analog of the amino acid lysine which exerts its effect by binding with the lysine-binding sites on the plasminogen molecule. It reversibly and competitively reduces the affinity of plasminogen binding with fibrin, decreases the activation of plasminogen to plasmin, and reduces the local degradation of fibrin by plasmin. Since its development in the early 1960s, TXA has been proven to be a remarkably effective drug in reducing perioperative blood loss and therefore the requirement for transfusion. 1,2 Nowhere has this been more apparent than in orthopedic surgery, especially in patients undergoing major joint replacement procedures. Until recently, concerns over TXA's theoretical potential to increase postoperative venous thrombotic events (VTE) have unfortunately delayed or even prevented its broader use among arthroplasty patients. Venous thrombotic events remain a concern in arthroplasty patients who are especially vulnerable to thrombotic complications postoperatively.Initial in vitro studies have shown that a concentration of 100 mgÁL -1 was required to produce a 98-100% reduction in fibrinolytic activity. 1 Subsequent clinical experience has shown that an 80% reduction in fibrinolytic activity was sufficient for clinical needs, and this was produced with a TXA concentration of 10 mgÁL -1 . 1 The optimal dose and route of administration to be used in arthroplasty patients remain unclear. In a recent meta-analysis, 46 randomized controlled trials involving 2,925 patients undergoing an orthopedic procedure were identified and included in the analysis. 3 In 21 studies, TXA was given in doses \ 15 mgÁkg -1 , and in 18 studies, TXA was given in doses [ 15 mgÁkg -1 . A single bolus given preoperatively was used in 20 studies, and repeated boluses were given in 26 studies. When all doses and schedules were pooled, TXA was associated with a mean reduction in total blood loss of -408 mL (95% confidence interval [CI], -506 to -311), leading to a halving of the likelihood of allogeneic blood transfusion (relative risk, 0.51; 95% CI, 0.46 to 0.56). Subgroup analysis showed that reductions in transfusion were similar in both single and multiple TXA dosing regimens. In addition, these authors did not observe any statistically significant increases in thromboembolic events. There were similar rates of deep venous thrombosis (DVT) in the TXA and control groups [30 of 1,376 (2.18%) patients and 26 of 1,313 (1.98%) patients, respectively; relative risk, 1.11; 95% confidence interval, 0.69 to 1.79].Despite the plethora of individual studies and meta-analyses, the routine use of TXA in this at-risk patient population has been limited by what some clinicians consider to be an insufficiency of data. This is mainly due to the small sample size of the majority of studies, thus requiring meta-analyses to characterize the safety and harm of therapy. A recent large retrospective cohort study drawn from administrative health data may have put some of these concerns to rest. 4 In this study of 872,4...

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Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality

et al. 2021

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IMPORTANCE Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use.OBJECTIVE To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines.DATA SOURCE Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020.STUDY SELECTION Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded.DATA EXTRACTION AND SYNTHESIS Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES Vascular occlusive events and mortality.RESULTS A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, −0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, −0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, −0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = −0.001; 95% CI, −0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, −0.005; 95% CI, −0.021 to 0.011; P = .53).CONCLUSIONS AND RELEVANCE Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of...

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Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety

Cited by 387 publications

References 28 publications

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation

Tranexamic acid: When is enough (data) enough?

Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality

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