From the perspective of a practicing hemostaseologist and anesthetist in a large orthopedic center that provides mostly elective surgery, patients after cardiovascular events, some of whom have been taking anticoagulants or antiplatelet drugs for a very long time, present a routine challenge.
For these patients we were not able to conclude any precise recommendations for how to act regarding tranexamic acid (TXA). Even its therapeutic use in severe hemorrhages requires careful balancing of the necessity of stopping the bleed and possible prothrombotic effects.
For this reason, we think that it cannot be emphasized enough that patients at risk of thromboembolism—in addition to the necessary information on off-label use—should not only be given a clear explanation of the risks but should not receive any prophylactic application of TXA either.
In view of the large number of studies of the use of TXA in elective orthopedic patients, it should be made clear that such at-risk patients were excluded from the studies. Furthermore, the studies were not conceived—in terms of the number of cases included—to investigate rare events, such as postoperative thromboembolism.
Furthermore, we are lacking valid studies investigating systemic pharmacokinetics after local or topical administration in patients with, for example, impaired renal function.
Although conceptually it is reasonable that the general postoperative thrombosis risk after endoprosthetic surgery falls as a result of early mobilization of the patient (1), but the pre-emptive use of tranexamic acid should then also be assessed in the same context.
We need reliable data before extending this indication with a clear conscience to include patients at risk of thromboembolism—as doctors we are obliged to the rule “First, do no harm.”
Dr. med. Thomas Schachtner
Zentrum für Anaesthesiologie,
Intensivmedizin und Schmerztherapie
Schön Klinik München-Harlaching
Prof. Dr. med. Michael Spannagl
Hämostaseologie, Hämophiliezentrum und hämostaseologisches Speziallabor
Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie
Klinikum der Universität München
|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|