The key role of tranexamic acid in Patient Blood Management programmes

Thanks to their high efficacy in improving clinical outcomes in surgical patients, patient blood management programmes have been developed rapidly worldwide in the last decade^1,2. Patient blood management is an evidence-based, multi-disciplinary and patient-centred model based on three pillars, i.e. optimisation of endogenous erythropoiesis, minimisation of bleeding and blood loss and optimisation of the physiological reserve of anaemia^3,4. Each of these pillars applies, through various strategies, to a definite surgical period (i.e., intra-operative, pre-operative and post-operative). Among the various peri-operative settings, orthopaedic surgery is that most extensively studied in the frame of patient blood management programmes and both transfusional and non-transfusional measures have been proposed^5–11. Among the latter, there is increasing interest in the use of the anti-fibrinolytic agent tranexamic acid, particularly after the publication of the results of two trials demonstrating that this synthetic haemostatic drug confers a survival benefit in the setting of severe trauma and of post-partum haemorrhage^12,13. Tranexamic acid has indeed been widely used to minimise bleeding and exposure to allogeneic blood transfusion in major orthopaedic surgery and several large randomised clinical trials and meta-analyses have consistently confirmed that the intravenous administration of tranexamic acid could effectively and safely reduce peri-operative blood loss and transfusion requirements in total hip and knee arthroplasty¹⁴. In addition, a recent systematic review and meta-analysis of five randomised controlled trials involving 457 patients in whom combined intravenous and topical tranexamic acid was compared with intravenous use alone in total hip arthroplasty concluded for the superiority of the combination in terms of reduction of blood loss, haemoglobin decline and need for transfusion without increasing the rate of thromboembolic complications¹⁵. The safety and efficacy of topical tranexamic acid in total hip arthroplasty was further pointed out in another meta-analysis of 14 studies including 2,594 patients: the conclusions of this study were that, compared with placebo, the topically administered haemostatic agent significantly reduced total blood loss, drainage loss, transfusion rates and the decrease in haemoglobin level without increasing the risk of venous thromboembolism¹⁶. In addition, a recent meta-analysis of five trials with 1,614 participants comparing intravenous vs topical tranexamic acid found similar haemostatic effects and safety profiles between the two methods of administration suggesting a possible beneficial use of the topical route in patients at increased risk of thromboembolism¹⁷.

A further step forward on this issue has been provided by the study published in this issue of Blood Transfusion by Perez-Jimeno and colleagues¹⁸. In a prospective, single-centre, open-label randomised trial conducted on 249 patients (125 cases and 129 controls) undergoing total hip arthroplasty, the authors demonstrated that topical tranexamic acid was effective at reducing both post-operative red blood cell loss and transfusion rates with good tolerance and no clinically relevant adverse events. In particular, no thromboembolic complications were observed in association with the use of this anti-fibrinolytic agent.

Thanks to the results that emerge from this study, we have increased our knowledge on the efficacy and safety of topical tranexamic acid in major surgery. We are therefore strong convinced that the implementation of this therapeutic option along with other practices (early detection and treatment of pre-operative and post-operative anaemia, a restrictive transfusion strategy, policy of transfusing single units of red blood cells, etc.) will contribute significantly to the effectiveness of the patient blood management approach to surgical patients.