AAOS Now

Published 8/1/2018

Board Approves CPG From AAHKS on Tranexamic Acid

In addition to approving the two SLRs on oncology imaging referrals and surgical site infections, the AAOS Board of Directors endorsed a CPG prepared and submitted by the American Association of Hip and Knee Surgeons (AAHKS) in conjunction with the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Hip and Knee Societies covering use of tranexamic acid (TXA) in total joint arthroplasty (TJA).

The CPG is intended to address common questions related to the efficacy and safety of TXA in primary TJA. In developing it, the AAHKS guideline writers used the same methodology the AAOS employs for its CPGs, completing a series of direct and network meta-analyses to support its recommendations.

Yale Fillingham, MD, work group chair for the guideline, provided the following highlights:

  1. Administration of intravenous (IV), topical, or oral TXA, as well as combinations of individual formulations of TXA, are all effective strategies compared to placebo for reducing calculated blood loss and the need for transfusion during the perioperative episode of a primary TJA (strong recommendation).
  2. All methods of administration effectively demonstrate equivalent efficacy at reducing calculated blood loss and the risk of transfusion during the perioperative episode of a primary TJA (strong recommendation).
  3. Within the context of 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 (strong recommendation).
  4. Administration of multiple doses of IV or oral TXA compared to a single dose of IV or oral TXA does not significantly alter the amount of calculated blood loss or the need for transfusion during the perioperative episode of a primary TJA (strong recommendation).
  5. In primary TJA, administration of IV TXA before the incision potentially reduces blood loss and the need for transfusion compared to its administration after incision (moderate recommendation).
  6. Administration of IV, topical, or oral TXA in patients without a known history of a venous thromboembolic event (VTE) does not increase the risk of a VTE compared to placebo during the perioperative episode of a primary TJA (strong recommendation).
  7. Administration of TXA in patients of generally higher comorbidity burden (history of a VTE, myocardial infarction, cerebral vascular accident, transient ischemic attack, and/or vascular stent placement) does not suggest increasedrisk of adverse thromboembolic events during the perioperative episode of a primary TJA (moderate recommendation).
  8. The existing evidence does not suggest that TXA increases the risk of developing an arterial thromboembolic event compared to placebo during the perioperative episode of a primary TJA (moderate recommendation).

Dr. Fillingham commented, “The multidisciplinary committee included our anesthesia colleagues at ASRA, which proved to be an invaluable partnership. Their vantage point was especially helpful in formulating the recommendations regarding the safety of TXA. Although the literature lacks evidence of harm in administering TXA to ‘high-risk’ patients, we conversely lack definitive evidence regarding the safe administration among these patients. In the face of this obstacle, we looked toward the number needed to treat and number needed to harm as a guiding factor in our recommendation. We found the number needed to administer IV TXA to attribute a single VTE was 983 patients, while the number needed to treat with TXA to prevent a transfusion for a THA or TKA patient was only four and three, respectively. Despite a moderate level of evidence to support the safety of TXA in ‘high-risk’ patients, we believe these numbers help a clinician decide whether to administer or withhold TXA.”

He also noted, “AAHKS was fortunate to work closely with the AAOS Department of Research, Quality, and Scientific Affairs in completing the analysis for the CPG.”