Tranexamic Acid (TXA) is a synthetic amino acid which competitively blocks the lysine binding sites on plasminogen, thereby slowing the conversion of plasminogen to plasmin [1]. For instance, the early administration of TXA has been found to confer a survival benefit in the settings of severe trauma [2] and of post-partum hemorrhage without an increase in thromboembolic events [3]. Several large meta-analyses have confirmed that the intravenous administration of TXA could effectively and safely reduce perioperative blood loss and transfusion requirements in total hip and knee arthroplasty [4,5]. Moreover recent meta-analysis showed the safety and efficacy of topical tranexamic acid in total hip arthroplasty. However, they demonstrated that combined intravenous and topical tranexamic acid may be superior to intravenous or topical TXA alone [6]. 

Although TXA can be administered orally, intravenously or topically, the most appropriate route of administration and dose, as well as its efficacy and safety, are still a matter of controversy. Several meta-analyses have shown the efficacy of topical and intravenous TXA in reducing blood loss and RBCT requirements in several clinical settings [7] In a recent open label randomized trial regarding total hip arthroplasty the authors demonstrated that local tranexamic acid reduced blood loss and transfusion in the post. Besides that, no thromboembolic complications were observed [8]. Patient Blood Management (PBM) is a holistic approach to the management of blood as a resource for each, single patient; it is a multimodal strategy that is implemented using a set of techniques that can be applied in individual cases [9]. The concept of PBM can be achieved optimizing the patient's erythropoiesis, minimizing bleeding and exploiting an individual's physiological reserve to tolerate anemia.        

Therefore, the combination of topical and intravenous tranexamic acid would contribute to the patient blood management program in elective major orthopedic surgery in adults reducing blood loss and blood transfusion.

1.       Mannucci PM (1998) Hemostatic drugs. N Engl J Med 339: 245-253.

2.       Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 376: 23-32.

3.       WOMAN Trial Collaborators (2017) Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 389: 2105-2116.

4.       Moskal JT, Capps SG (2016) Meta-analysis of intravenous tranexamic acid in primary total hip arthroplasty. Orthopedics 39: e883-92

5.       Wei Z, Liu M (2015) The effectiveness and safety of tranexamic acid in total hip or knee arthroplasty: a meta-analysis of 2720 cases. Transfus Med 25: 151-162.

6.       Zhang P, Liang Y, Chen P, Fang Y, He J, et al. (2017) Combined application versus topical and intravenous application of tranexamic acid following primary total hip arthroplasty: a meta-analysis; BMC Musculoskeletal Disorders 18: 90.

7.       Montroy J, Hutton B, Moodley P, Fergusson NA, Cheng W, et al. (2018) The efficacy and safety of topical tranexamic acid: A systematic review and meta-analysis; Transfus Med Rev 2018.

8.       Pérez-Jimeno N, Muñoz M, Mateo J, Mayoral AP, Herrera A, et al. (2018) Efficacy of topical tranexamic acid within a blood-saving programme for primary total hip arthroplasty: a pragmatic, open-label randomised study; Blood Transfus 16: 490-497.

9.       Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, et al. (2016) Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults Blood Transfus 14: 23-65.