Are we scientifically ready to adopt tranexamic acid as a routine in arthroplasty?

The orthopedic literature is abundant in studies on use of tranexamic acid (TXA); most showing its effectiveness in reducing blood loss and transfusion requirement leading to better outcome, shorter length of hospital stay and reduced costs.[1,2] History of TXA dates back to 1960s and TXA is a relatively cheap agent. However, being old and cheap have not restrained TXA to revolutionize the perioperative blood management in the last decade of orthopedic practice, particularly in arthroplasty procedures which make up for a big portion of elective surgeries.[3-5] However, despite the great interest in and the enthusiasm surrounding this agent, its pharmacokinetic characteristics, dosing and optimal modality of administration for different clinical scenarios still remain largely unknown. Tranexamic acid is a fibrin clot stabilizer and not actually a pro-coagulant agent, but it is still commonly associated with increased risk of venous thromboembolic events (VTEs) (e.g. stroke, deep venous thromboembolism, pulmonary embolism), myocardial infarction and to a lesser extent, retinal injury, seizures and nausea. Although this increased risk profile has not been demonstrated, neither it has been totally ruled out in arthroplasty procedures. Considering that even the meta-analyses including data from highest quality randomized controlled trials struggle to provide concrete evidence on safety of TXA use and, for prospective studies, there is need for at least 5,000 patients in each group even to detect a 1% difference with an 80% power, TXA’s widespread adoption seems to continue lacking strong scientific background.[6,7] It has also not been approved by the U.S. Food and Drug Administration for uses other than dental bleeding prophylaxis in hemophilic patients and menorrhagia.[8,9]