We agree with Schachtner and Spannagl that insufficient data exist to support the prophylactic administration of tranexamic acid (TXA) in patients at risk of thromboembolism and that for this reason—in our view—TXA should be administered only in the context of individualized shared decision-making. We pointed this out several times in our article (1).
Topical application of TXA seems to be a possible administration route that should—at least when thinking in mechanistic terms—result in very little systemic change in terms of procoagulation. For reasons of space, however, we did not mention this application mode in detail in our article, even though good proof of efficacy exists (albeit there are hardly any risk analyses) (2, 3).
We do not think, however, that (topical) TXA application in patients with a history of thromboembolic events—as stipulated by Schachtner and Spannagl—is absolutely contraindicated. First, doing no harm, as also stipulated, would then mean that clinicians will always abstain from the (topical) application of TXA in patients with thromboembolic risks and a high perioperative transfusion risk. The lack of data on the safety of a substance is therefore used as an argument to justify the increased transfusion rate—for which sufficient data exist—and possible side effects.
We support the complete implementation of the citation: first, do no harm; second, be cautious; third, heal. The second and third aspects—second, be cautious; third, heal—should not be forgotten.
In our hospital, the colleagues involved in the perioperative setting—from the disciplines of anesthesiology, orthopedics, and hemostaseology—collaborate closely, and patients at high risk of hemorrhage are given detailed information about individual prophylaxis using (topical) TXA as a single treatment in the context of the integrated therapeutic concept.
On behalf of the authors
Klinik für Anästhesie und Intensivtherapie
Universitätsklinikum Gießen und Marburg (UKGM)
Conflict of interest statement
The authors of both contributions declare that no conflict of interest exists.
|1.||Goldstein M, Feldmann C, Wulf H, Wiesmann T: Tranexamic acid prophylaxis in hip and knee joint replacement. Dtsch Arztebl Int 2017; 114: 824–30 VOLLTEXT|
|2.||Alshryda S, Sukeik M, Sarda P, Blenkinsopp J, Haddad FS, Mason JM: A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J 2014; 96: 1005–15 CrossRef MEDLINE|
|3.||Tao-ping C, Yu-min C, Jian-bao J, et al.: Comparison of the effectiveness and safety of topical versus intravenous tranexamic acid in primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2017; 12: 1–11 CrossRef PubMed Central|