IV and Topical TXA Comparable in Safety and Efficacy During Joint Replacement Surgery

TXA administered either intravenously or topically was effective in decreasing the amount of blood transfusions in primary and revision hip and knee replacements.

Intravenous tranexamic acid (TXA) has been shown to be safe and effective in reducing blood loss and transfusion rates in joint replacement surgery, according to research presented at the American Academy of Orthopaedic Surgeons (AAOS) 2016 Annual Meeting in Orlando, Florida. Total joint arthroplasty is a treatment option for patients with severe, symptomatic osteoarthritis (OA) who have failed to respond to non-surgical management and have impaired quality of life secondary to OA.  

“We launched the study, as conflicting results have been published regarding the use of TXA in patients undergoing hip and knee replacement,” Geoffrey Westrich, MD, director of research in the Adult Reconstruction and Joint Replacement Service at the Hospital for Special Surgery, said in a statement. “There was also concern regarding a potential increased risk of a blood clot, although previous studies have shown this drug to be safe.”

To examine the safety and effectiveness of intravenous (IV) TXA in primary unilateral, bilateral, and revision hip and knee arthroplasty, the researchers retrospectively reviewed records from 4,449 patients who had hip or knee replacement from November 2013 to May 2014. Of those patients, 720 received TXA topically, 636 received TXA intraveniously, and 3093 received no TXA.

The researchers found TXA to be safe and effective, reducing the need for a blood transfusion by more than 50%. Patients who received TXA received an average of 0.13 units of blood compared with 0.37 units of blood for those who did not receive TXA. The researchers found no significant difference in effect between intravenously (IV) administered TXA and topical TXA

While Dr Westrich noted that due to the increased thrombosis risk, IV TXA should not be used in patients who have had a previous blood clot or in those who have a cardiac stent, and that in patients who could not receive intravenous TXA, topical TXA was just as effective.

The chances of a patient who received TXA developing a hospital-acquired venous thromboembolism was 1.63 (95% confidence interval [CI], 0.72-3.69) compared with the odds of patients who did not receive TXA, but this was not statistically significant (P=.24). The researchers did find a statistically significant increase in deep venous thromboembolism with the use of TXA (P=.03) but not pulmonary embolism (P=.94).

“At our institution, TXA in either intravenous or topical form was effective in decreasing the amount of blood transfusions, as well as the number of units of blood transfused in primary and revision hip and knee replacement,”Dr Westrich said in a statement.

“Furthermore, when safety was evaluated, there was no statistically significant increase in venous thrombotic events in this patient population as a group, although there was a slight increase in deep venous thromboembolism, but not pulmonary embolism,” the researchers wrote.

More studies are needed comparing various doses and combining IV and topical TXA in order to determine what would provide patients with the greatest benefit, Dr Westrich concluded.

Summary and Clinical Applicability

Antifibrinolytics have been successfully used to decrease blood loss during surgery. In orthopedic surgery, the use of the lysine analog TXA has been shown to effectively decrease estimated blood loss, need for transfusion, and total amount of blood transfused for particular surgeries.2   

In the joint replacement patient population included in this study, TXA administered either intravenously or topically was effective in decreasing the amount of blood transfusions in primary and revision hip and knee replacements. There was no significant difference in the antifibrinolytic effects of TXA when administered topically and intravenously. No increases in thrombosis were noted with the IV TXA administration as compared to topical TXA administration. 

It is important to note that because of the increased risk for thrombosis with antifbrinolytics, this study excluded patients with history of DVT, PE, thromboembolic disease, or cardiac stent. Additionally, the blood loss estimations may have been impacted by hemodilution.

Larger prospective, cohort studies comparing the efficacy of various doses of IV TXA need to be done.

Summary and Clinical Applicability Statement by Corinna Panlilio Sison, MD


1. Kao YJ, Prashker BL, Westrich GH. Topical versus intravenous tranexamic acid in hip and knee arthroplasty: efficacy and safety. Presentation P101. Presented at: 2016 meeting of the American Academy of Orthopaedic Surgeons. March 1-5, 2016; Orlando, Florida.

2. Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ. 2012;344:e3054.

This article originally appeared on Clinical Pain Advisor