Tranexamic acid Flashcards
(7 cards)
MOA
Inhibits Fibrinolysis by blocking the conversion of
Plasminogen —>Plasmin
TXA is a synthetic analog of Lysine. It binds to lysine binding sites on Plasminogen and prevents conversion to plasmin
Directly inhibits Plasmin at higher concentrations.
Binding - Reversible and competitive
Evidence in Cardiac sx patients
Summary:
Use of TXA results in decreased risk of bleeding and need for transfusion
Slight increase in risk of seizures
No significant difference in risk of death/ thrombotic complications
In our institute, we use low dose TXA in pts undergoing cardiac Sx with a further dose if post op bleeding occurs.
ATACAS— TXA vs Placebo
-2017, multicentre including ANZ
- Adult elective CABG pts
- Does TXA increase risk of death /thrombotic complications in 30 days
-Results
- No increase in risk of death or thrombotic complications
-TXA - asso with lower risk of bleeding
- clinically significant reduction in rate of return to theatre
- Decreased transfusion req
*Increase in seizure risk by 0.57%
*The OPTIMAL RCT
Effect of high vs low dose TXA in cardiac sx pts in need for blood Tx and adverse effects
Results:
-Significant decrease in Tx req with high dose
Noninferior to low dose in
-30 day mortality
- seizures
- thrombotic complications
- Renal dysfunction
TXA in GI bleed
Summary:
TXA does not reduce mortality in GI bleed and its routine use not recommended
Cochrane r/v in 2012- found a reduction in mortality with TXA but studies included- lower external validity
Halt it :
Purpose-Does high dose TXA in patients with GI bleed reduce mortality when compared to placebo
Dose- 1gm over 1hr foll by 3gm over 24hrsor
Result- no diff in death due to bleeding in 5days foll randomisation or at 28days
Systematic review and meta analysis - high dose TXA does not reduce mortality in GI bleed but may increase adverse events
Low dose TXA- may reduce mortality but larger studies needed
TXA in Trauma
CRASH -2
Trauma patients with a risk of significant haemorrhage —does early dose of TXA affect mortality, transfusion of blood products or vaso- occlusive events
1gm of TXA within 3hrs of trauma foll by 1gm over 8hrs
Result-
Reduction in all cause mortality
Reduction maximum when given early.
No diff in risk of thrombosis/ req for blood tx.
Criticism:
No attempt made to measure Fibrinolysis
Anti inflammatory effects of TXA may account for some of the mortality difference
Bleeding- not the major cause of death in patients who died
If TXA was given later than 3hrs- increased risk of death from bleeding.
CRASH 3
Effect of TXA on Death, Disability, VTE in pts with TBI
Result:
*Significantly reduced 28day mortality in patients with mild to moderate TBI but
*No significant difference in pts with severe TBI and
*No significant difference in overall inhospital mortality at 28days
*No difference in Disability among two groups
*No increased risk of VTE/complications
TAMPITI
Evaluated effect of TXA on coagulation profile
Result:
Minimal impact on real time coagulation but dose dependent increase in risk of VTE
PATCH-
ANZICS trial
Patients with Trauma at risk of coagulopathy - does TXA 1gm foll by 1gm over 8hrs reduce mortality with favourable functional outcomes at 6mths
Result:
No significant diff in
- early mortality or at 6mths or
-VTE
-no improvement in functional outcomes in pts who survived
TXA in Intracerebral bleed
Summary:
No overall benefit observed but risk of adverse effects is quite low hence can be used for potential observed benefits in ICH
Summary:
No clear evidence for benefit of TXA in SAH. Given the risk of DCI, I would not use it in my patients.
TICH-2
Does TXA improve functional outcomes in in pts with acute ICH at 90 days
Results:
No improvement in functional outcomes at 90 days but some benefits observed in terms of reduction in
-haematoma expansion,
-Early death and
-No. Of serious events.
Ultra:
Does ultra early short term TXA improve functional outcomes at 6months in patients presenting with SAH
Result: No significant improvement in functional outcomes
TXA in Caesarian section
TRAAP 2
Does TXA result in reduced blood loss/ blood Tx in pts undergoing CS
Results:
Reduced incidence of PPH in TXA group but no difference in
Clinically significant blood loss/ transfusion requirements
TXA in PPH
Some serious limitations:
Change in power calculations and
Hypothesis after study was commenced
Very low fragility index
But TXA should be used in all cases of PPH in view of good safety profile and low cost
WOMAN trial
Does TXA reduce death from bleeding in pts with PPH
Results:
Statistically significant reduction in death due to bleeding in PPH
Though no difference in primary composite outcome of death from all causes or hysterectomy
