In this post I link to Emergency Medicine Cases’ Journal Jam 18 The Evidence for TXA – Should Tranexamic Acid Be Routine Therapy in the Bleeding Patient?*
*Helman, A. Morgenstern, J. Milne, K. Journal Jam 18 – The Evidence for TXA – Should Tranexamic Acid Be Routine For The Bleeding Patient. Emergency Medicine Cases. June, 2021. https://emergencymedicinecases.com/evidence-txa-tranexamic-acid-bleeding. Accessed 7/2/2021.
Dr. Helman writes in the introduction:
TXA has been widely adopted as an effective drug for improving outcomes of patients who are bleeding from a variety of sources, even though many of the trials’ conclusions are contentious. One of the major concepts we have discussed on the Journal Jam Podcast is that prior probability matters. When assessing a trial, one’s interpretation is often shaped by the science that is already available. So when trying to determine how to interpret a somewhat controversial study like CRASH-3, it is really helpful to take a deep dive into all the available evidence for TXA. This will help us decide when to use TXA in the ED and to gain a broad understanding of this drug. That is our goal here. With the help of a special guest, EBM guru Dr. Ken Milne of the The SGEM, Anton and Justin look at all the various potential indications for TXA and review the available evidence. Should we be using TXA for epistaxis, postpartum hemorrhage, hyphema or hemoptysis? Is it a miracle drug that stops all bleeding? Or has it been drastically overhyped? Was CRASH-2 enough to be definitive, or does the classic EBM mantra of “we need more studies” remain true?…
And this podcast and show notes thoroughly address these questions. In addition, they are a beautiful example of how to use Evidence Based Medicine to analyze atopic.
From the show notes, a summing up:
Timing and safety of TXA
While there is some suggestion that the earlier TXA is given the better, it may also be true that the later it is given, the more harms such as thromboembolic events, and possibly even mortality. Although, overall TXA appears to be a safe drug, there is likely a small increase in thromboembolic events in patients receiving TXA, which should be taken into account, especially for patients with thromboembolic risk factors.
Take home points for TXA in bleeding patients
- The pattern of research findings for TXA for most indications is that small, lower quality studies are positive, fueling the use of TXA in practice, while large higher quality studies are negative
- Only a single high quality large RCT has shown TXA to significantly reduce all-cause mortality
- While it may be true that the earlier TXA is given after bleeding commences the better, it may also be true that the later it is given, the more harms it portends
- Conclusions drawn from subgroup analyses should generally be considered hypothesis generating, and not practice-changing
- Replication of study results in essential for widespread evidence-based adoption of a drug in practice
- It is important to attempt to weigh the risk to the patient of ongoing bleeding, the patient’s hemodynamics, the ability of the patient to compensate for blood loss, the patient’s thromboembolic risk factors and the patient’s values in deciding whether or not to administer TXA in any given clinical scenario