TRANEXAMIC ACID
In the absence of reliable evidence, it is the opinion of the workgroup that utilization of tranexamic acid during shoulder arthroplasty may result in reduced blood loss and reduced risk of blood transfusion

Rationale

While the topic of tranexamic acid (TXA) use in the setting of shoulder arthroplasty has been studied, high quality evidence does not currently exist on its use in the setting of patients with glenohumeral joint osteoarthritis (OA) undergoing surgical treatment. Thus, only a consensus level recommendation is made here. However, a number of clinical studies1-7 have shown a reduction in perioperative blood loss with the use of TXA in patients undergoing primary shoulder arthroplasty (anatomic and reverse total shoulder). Two recent meta-analysis8,9 which included all but one of the aforementioned clinical studies (3 randomized controlled trials and 3 retrospective cohort studies) concluded that administration of TXA was associated with a significant reduction in the postoperative change in hemoglobin concentration, drain output, total blood loss and a trend toward reduction in rate of blood transfusions. A total of 680 patients were included in the meta-analysis and combined both primary anatomic and reverse shoulder arthroplasty and there was marked heterogeneity of TXA regimens used in each study.

 

Benefits & Harms:

Tranexamic acid treatment appears to be associated with reduction in perioperative blood loss after primary shoulder arthroplasty and the benefits of decreasing blood loss after surgery are apparent.  At the same time, tranexamic acid use in patients appears to be safe. A recent meta-analysis9 of 680 patients undergoing primary shoulder arthroplasty (3 Level I and 3 Level III studies) found no significant difference in the overall complication rate nor the rate of thromboembolic events between the TXA and non-TXA groups.

 

Cost Effectiveness/Resource Utilization:

Tranexamic acid is known to be a very inexpensive drug that is highly cost-effective.10

 

Future Research: 

Further study is needed to determine the optimal dosing and route of administration of TXA. The studies that have been performed to date have included varying drug doses and frequency and have also differed in mode of administration (intravenous or topical). Additionally, the majority of the studies have pooled together both anatomic and reverse shoulder arthroplasty and more data is needed to determine its efficacy in each alone. Additionally, while there is no evidence of increased complication to date, including any increased risk of thromboembolic phenomenon, future studies on the safety of TXA use in shoulder surgery is needed.

 

Additional References:

Abildgaard, J.T., McLemore, R., Hattrup, S.J., Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(10):1643-1648.

Friedman, R.J., Gordon, E., Butler, R.B., Mock, L., Dumas, B., Tranexamic acid decreases blood loss after total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(4):614-618.

Gillespie, R., Shishani, Y., Joseph, S., Streit, J.J., Gobezie, R., Neer Award 2015: A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(11):1679-1684.

Kim, S.H., Jung, W.I., Kim, Y.J., Hwang, D.H., Choi, Y.E., Effect of Tranexamic Acid on Hematologic Values and Blood Loss in Reverse Total Shoulder Arthroplasty. BioMed Research International. 2017;2017(3):9590803-9590805.

Pauzenberger, L., Domej, M.A., Heuberer, P.R., et al. The effect of intravenous tranexamic acid on blood loss and early post-operative pain in total shoulder arthroplasty. Bone Joint J. 2017;99-B(8):1073-1079.

Vara, A.D., Koueiter, D.M., Pinkas, D.E., Gowda, A., Wiater, B.P., Wiater, J.M., Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial. J Shoulder Elbow Surg. 2017;26(8):1383-1389..

Cvetanovich, G.L., Fillingham, Y.A., O'Brien, M., et al. Tranexamic acid reduces blood loss after primary shoulder arthroplasty: a double-blind, placebo-controlled, prospective, randomized controlled trial. JSES Open Access. 2018;2(1):23-27.

Box, H.N., Tisano, B.S., Khazzam, M., Tranexamic acid administration for anatomic and reverse total shoulder arthroplasty: a systematic review and meta-analysis. JSES Open Access. 2018;2(1):28-33.

Kuo, L.T., Hsu, W. H., Chi, C. C., Yoo, J.C., Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2018;19(1):60–13.

Kirsch, J.M., Bedi, A.B., Horner, N., et. al. Tranexamic acid in shoulder arthroplasty: a systematic review and meta-analysis. 2017; 5(9):e3

 


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