In this episode, I’ll discuss whether tranexamic acid has a role in the treatment of aneurysmal subarachnoid hemorrhage.
Tranexamic acid is an antifibrinolytic agent that inhibits the conversion of plasminogen to plasmin. This results in the inhibition of fibrinolysis and should promote the stabilization of a clot that is forming in response to a bleed. Because this mechanism is not directly prothrombotic, tranexamic acid is generally considered to have less of a clotting risk than other strategies like the administration of clotting factors.
While early surgical treatment is preferred for the management of aneurysmal subarachnoid hemorrhage, tranexamic acid has been proposed when early surgical treatment is not available, or after surgical treatment to reduce the risk of rebleeding.
Because this use of tranexamic acid is controversial, the journal Academic Emergency Medicine published a systematic review of randomized controlled trials of patients diagnosed with SAH and suspected or confirmed ruptured aneurysm that were randomized to tranexamic acid or placebo and were awaiting surgical management.
This review included 13 trials with nearly 3000 patients. All but one trial used IV tranexamic acid (one used the oral form), and the most popular regimen studied was a 1g IV dose followed by some sort of maintenance dosing schedule at various durations.
The review determined that tranexamic acid was not associated with any effect on mortality. This was true whether the duration of tranexamic acid use was less than 3 days, more than 3 days, and if mortality was assessed in the short-term or at 90-days.
There was also no effect of treatment on poor functional outcome.
Adverse events did not differ between tranexamic and placebo groups, including cerebral ischemia and deep venous thrombosis events.
The only difference that was in favor of the tranexamic acid group was an 8.7% absolute reduction in rebleeding events.
Because the difference in rebleeding is a secondary outcome and was not associated with any clinically meaningful benefits such as a reduction in mortality or improved chance of a positive outcome, the authors of the review assigned a rating of “no benefit” to tranexamic acid in this setting. The authors also urged caution if concluding that tranexamic acid has no risk of adverse events in this population because it is possible that a small difference could exist but not have been detected due to the insufficient power of the studies.
Members of my Hospital Pharmacy Academy have access to practical training on the potential uses of tranexamic acid. You can get immediate access to this and hundreds of other trainings and resources to help in your practice at pharmacyjoe.com/academy.
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Hey Pharmacy Joe, its pharmacy Mike. Great Topic!