When Can We Use Tranexamic Acid?

Lately, I have noticed some changes on the usage of tranexamic acid. In the past, it would be contraindicated to use on patients who had a history of stroke, DVT, A-fib, valvular disease, or SAH. Recent studies have shown that the use of TXA doesn’t significantly increase the embolic event in surgical patients. In our institution, we have updated our clinical practice based on the recent clinical stuides. So I figure it would be good to update this topic in my blog since we use it so often particularly in total joints and spine cases.

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First of all, lets go back to the basics. TXA is anti-fibrinolytic derivative of lysine. It competitively inhibits activation of plasminogen through reversible interactions with lysine-binding sites on the enzyme. In addition, it non-competitively inhibits plasmin at higher concentrations. Hence, it effectively prevents the breakdown of the clog.We often use the TXA in total joints and cardiac surgery. The use of TXA in obstetric surgery is controversial. TXA passes through placenta and FDA categorizes TXA as a category B drug. However, in the event of postpartum hemorrhage, WHO recommends the use of TXA if the first and second line of uterotonic drugs are ineffective. There were two randomized control trials demonstrating significant reduction of blood loss with administration of TXA in vaginal and cesearean sections. I have personally used a couple of times in postpartum hemorrhage after cesearean section and it saved patient’s life.

INDICATIONS

    • decrease peri-operative bleeding (e.g. prior to repeat cardiac surgery, total knee arthroplasty and total hip arthroplasty and cesarean section)
    • reverse thrombolytic therapy
    • dental bleeding (treatment, also prevention for dental extraction in hemophilia)
    • epistaxis
    • hemoptysis
    • hyphaema (decrease rates of rebleeds)
    • hereditary angioneurotic edema
    • hemorrhagic shock (trauma, surgical hemorrhage and obstetric hemorrhage)
    • adjunctive therapy for NOACs (benefit uncertain)

ABSOLUTE CONTRAINDICATIONS

    • Hypersensitivity to tranexamic acid
    • Acquired defective color vision
    • Active intravascular clotting
    • Subarachnoid hemorrhage, (may increase cerebral ischaemic complications)

     

Take home message on TXA: you can give TXA to patient who had  a history of stroke, A-fib, valvular disease,DVT and hemorrhaging c-seciton patient!

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