There is strong evidence that the use of high-dose tranexamic acid (TXA) is not associated with an increased risk of medical complications, compared to low-dose TXA or placebo, and there is moderate evidence to suggest that high-dose TXA reduces allogeneic transfusions compared to low-dose TXA. These are the key takeaways from a recent systematic review and meta-analysis, the results of which were presented at the Scoliosis Research Society’s (SRS) 57th annual meeting (14–17 September 2022; Stockholm, Sweden) by Han Jo Kim (New York, USA).
According to Kim et al, future research in this area should focus on procedures with large expected blood losses, in an effort to determine the exact risk-benefit relationship in patients with various medical conditions and describe the in vivo pharmacokinetics of TXA during spine surgery.
The researchers had hypothesised that, compared to low-dose TXA or placebo, high-dose TXA is not associated with a greater risk of medical complication.
The PubMed database was searched through December 2021 for studies in which high-dose TXA (defined as a loading dose ≥30 mg/kg or 2g) was given intravenously before spine surgery. Pooled complication rates were calculated. Meta-analyses were performed for outcomes of interest reported by at least two comparative studies. Articles were evaluated for risk of bias and strength of evidence assessments were given for each conclusion.
In total, 23 studies involving 2,331 patients were included, with a highest initial bolus of 100 mg/kg. The pooled medical complication rates were 3.2% for paediatrics and 8.2% for adults.
Using low-dose (any other TXA regimen) or placebo as the reference, meta-analysis showed no difference in medical complications or VTE (n=1,158; odds ratio [OD] 1.27; 95% confidence interval [CI], 0.61 to 2.63; p=0.528; I2=0%). In addition, no seizures occurred in any of the high-dose patient cohorts.
Compared to low-dose, high-dose TXA was associated with fewer perioperative transfusions (n=505; OR 0.28; 95% CI, 0.082 to 0.96; p=0.043; I2=76%) and a lower transfusion volume (n=434, weighted mean difference –228 mL; 95% CI, –377 to –78]; p = 0.003; I2 = 0%). Effect sizes were greatest in populations with the largest blood loss.
Speaking to Spinal News International, Kim said: “High-dose TXA should be the new standard in complex spinal deformity surgery, as it appears to minimise blood loss resulting in less blood transfusions.
“While definitive conclusions cannot be made on safety due to the relative effect sizes of these studies, the culmination of evidence suggests there is little to no difference in risks for previously feared TXA-related complications, such as thromboembolic events and seizures.”