Dosing
Within the context of the TXA doses used in primary TJA, the dose amount of TXA was not found to significantly affect its reduction of calculated blood loss or the need for transfusion during the perioperative episode of a primary TJA
Tranexamic Acid in Total Joint Arthroplasty
Developed by the American Association of Hip and Knee Surgeons
STRONG RECOMMENDATION Rationale
Due to a limited number of studies, direct meta-analysis could not be performed on the six high quality publications that solely investigated the dose effect of either IV or topical TXA.2,3 Only two of the published studies observed a difference in favor of higher doses of IV or topical TXA.4,5 However, two different studies investigating the same comparative doses of topical TXA (1.5g and 3g) in primary TKA did not observe a difference in calculated blood loss or risk of transfusion with higher doses of topical TXA.6,7 Additionally, two publications of IV TXA in THA or TKA did not favor higher doses of IV TXA.8,9 When a network meta-analysis was performed regarding the dose effect of IV or topical TXA, it demonstrated limited evidence for a reduction in either transfusion risk or calculated blood loss with higher doses of TXA.2,3
Although a dose response has only been observed in the analysis of TKA for IV TXA with the risk of transfusion, it does not preclude the presence of a dose response for IV or topical TXA. The anticipated dose response is likely not present at the levels of blood loss or the doses of TXA utilized for primary THA or TKA. In the network meta- analysis of primary THA and TKA, the range of IV TXA doses were 10 mg/kg and three doses of 15 mg/kg while for topical TXA doses the range was between 0.5g and 3g.2,3
Intravenous Tranexamic Acid
Network meta-analysis demonstrates no additional reduction in blood loss following a hip or knee arthroplasty with high dose IV (≥ 20mg/kg or > 1g) TXA compared to low dose IV (< 20mg/kg or ≤ 1g) TXA.4,5 A dose response was observed in the network meta-analysis with a reduced risk of transfusion for higher doses of TXA in primary TKA, but similar results were not found for primary THA.2,3 Additional evidence shows no significant difference comparing single-dose and multiple doses of IV TXA, which further supports the notion that higher doses of IV TXA are not necessarily clinically needed to improve the blood-sparing effects in the setting of hip or knee arthroplasties.2-3
Topical Tranexamic Acid
Direct meta-analysis and network meta-analysis consistently reported no statistical difference between low dose (≤ 1.5g) and high dose (> 1.5g) topical TXA.2-3 A dose response was not observed for either blood loss or risk of transfusion regarding low dose or high dose topical TXA following hip or knee arthroplasty.2,3
Although a dose response has only been observed in the analysis of TKA for IV TXA with the risk of transfusion, it does not preclude the presence of a dose response for IV or topical TXA. The anticipated dose response is likely not present at the levels of blood loss or the doses of TXA utilized for primary THA or TKA. In the network meta- analysis of primary THA and TKA, the range of IV TXA doses were 10 mg/kg and three doses of 15 mg/kg while for topical TXA doses the range was between 0.5g and 3g.2,3
Intravenous Tranexamic Acid
Network meta-analysis demonstrates no additional reduction in blood loss following a hip or knee arthroplasty with high dose IV (≥ 20mg/kg or > 1g) TXA compared to low dose IV (< 20mg/kg or ≤ 1g) TXA.4,5 A dose response was observed in the network meta-analysis with a reduced risk of transfusion for higher doses of TXA in primary TKA, but similar results were not found for primary THA.2,3 Additional evidence shows no significant difference comparing single-dose and multiple doses of IV TXA, which further supports the notion that higher doses of IV TXA are not necessarily clinically needed to improve the blood-sparing effects in the setting of hip or knee arthroplasties.2-3
Topical Tranexamic Acid
Direct meta-analysis and network meta-analysis consistently reported no statistical difference between low dose (≤ 1.5g) and high dose (> 1.5g) topical TXA.2-3 A dose response was not observed for either blood loss or risk of transfusion regarding low dose or high dose topical TXA following hip or knee arthroplasty.2,3
- Barrachina B, Lopez-Picado A, Remon M, Fondarella A, Iriarte I, Bastida R, Rodríguez-Gascón A, Achaerandio M, Iturricastillo M, Aizpuru F, Valero C, Tobalina R, Hernanz R. Tranexamic Acid Compared with Placebo for Reducing Total Blood Loss in Hip Replacement Surgery: A Randomized Clinical Trial. In: Anesthesia and analgesia. 986. 2016
- Carvalho LH, Jr., Frois Temponi E, Machado Soares LF, Goncalves MB, Paiva Costa L, Tavares de Souza ML. Bleeding reduction after topical application of tranexamic acid together with Betadine solution in total knee arthroplasty. A randomised controlled study. Orthopaedics & traumatology, surgery & research 101(1): 83, 2015
- Fillingham YA RD, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-Analysis. Journal of Arthroplasty, 2018
- Lin P, Hsu C, Huang C, Chen W, Wang J. The blood-saving effect of tranexamic acid in minimally invasive total knee replacement: is an additional pre-operative injection effective? In: The Journal of bone and joint surgery British volume. 932. 2012
- Maniar R, Kumar G, Singhi T, Nayak R, Maniar P. Most effective regimen of tranexamic acid in knee arthroplasty: a prospective randomized controlled study in 240 patients. In: Clinical orthopaedics and related research. 2605. 2012
- Sarzaeem MM, Razi M, Kazemian G, Moghaddam ME, Rasi AM, Karimi M. Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty. Journal of Arthroplasty 29(8): 1521, 2014
- Wong J, Abrishami A, El Beheiry H, Mahomed NN, Roderick Davey J, Gandhi R, Syed KA, Muhammad Ovais Hasan S, De Silva Y, Chung F. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. Journal of Bone & Joint Surgery - American Volume 92(15): 2503, 2010