“The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis” Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, Tinmouth A, Lavallee LT, Fergusson DA, Breau RH. Transfus Med Rev. (2018); [epub ahead of print]
It is well recognized that tranexamic acid (TXA), a lysine analogue, effectively and safely reduces blood loss in orthopedic and cardiac surgery, however caution has been recommended due to a theoretical risk of thrombotic events and seizures. Topical TXA, applied directly to the surgical site has been hypothesized to mitigate these risks, especially in patients at risk for venous thromboembolic (VTE) events or seizures. The authors present a meta-analysis of 67 randomized controlled trials assessing safety and efficacy of topical TXA use compared to either placebo or intravenous (IV) TXA, primarily in orthopedic surgery, cardiac surgery, dental surgery, and spinal surgery. When compared to placebo, the authors found that the topical TXA administration significantly reduced both blood loss and transfusion rates. When topical TXA was compared to IV TXA, efficacy was similar, for transfusion rate and blood loss. With respect to safety, no increased risk of VTE or mortality was noted when topical TXA was compared to placebo or IV TXA. Limitations are as follows. Due to the heterogeneity of the studied populations, further studies regarding topical TXA use in non-orthopedic surgery patients are necessary to assess efficacy and safety with regards to reducing blood loss and thrombotic event frequency, respectively. Additionally, the authors do not report the risk of seizures with topical TXA compared to systemic TXA or placebo. Furthermore, the authors do not compare the dose or cost of these two treatments. In summary, this meta-analysis shows that topical TXA has similar efficacy as systemic TXA in reducing both bleeding and transfusion, with no difference in the risk of VTE, however, the risk of seizures and overall cost were not reported in this study. In terms of changing clinical practice, in our opinion this study supports systemic over topical TXA use, since efficacy and safety are the same, and the IV administration route is likely easier, less expensive, and faster.
Vincent DeMario BS†
Mereze Visagie BA†
Steve M. Frank MD†‡
† Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
‡ Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA