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. 2021 Jul 14;5(5):e12546. doi: 10.1002/rth2.12546

Tranexamic acid evidence and controversies: An illustrated review

Nicole Relke 1,✉, Nicholas L J Chornenki 1, Michelle Sholzberg 2,3,4
PMCID: PMC8279901  PMID: 34278187

Abstract

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA persists in many clinical settings. This illustrated review describes the history, pharmacology, and practical considerations of TXA use. We also describe the major landmark randomized controlled trials of TXA and their implications. Finally, we review the evidence around common controversies surrounding TXA such as the risk of thrombosis, prescription along with combined hormonal contraceptives, and use in patients with gross hematuria.

Keywords: antifibrinolytic agents, blood coagulation, contraceptive agents, thrombosis, tranexamic acid

Essentials.

  • Tranexamic acid (TXA) decreases the risk of bleeding and often the risk of death from bleeding.

  • In general, TXA does not increase the risk of blood clots.

  • Consider shared decision making in patients taking TXA and combined hormonal contraceptives.

  • It is unknown if TXA causes harm in patients with blood in the urine.

TXA ILLUSTRATED REVIEW

Reference citations 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74

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RELATIONSHIP DISCLOSURE

The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS

NR and MS conceived and designed the manuscript. NR, NLJC, and MS wrote the paper.

ACKNOWLEDGMENTS

Select images in this review were taken from https://smart.servier.com and are licensed under a Creative Commons Attribution 3.0 Unported License. Blood drop image (pages 1, 4‐5, 9‐11) was purchased from shutterstock (stock vector ID: 641207020)

Relke N, Chornenki NLJ, Sholzberg M. Tranexamic acid evidence and controversies: An illustrated review. Res Pract Thromb Haemost. 2021;5:e12546. 10.1002/rth2.12546

Handling Editor: Alisa Wolberg.

Contributor Information

Nicole Relke, Email: nrelke@qmed.ca, @NicoleRelke.

Nicholas L. J. Chornenki, @NicholasJC95.

Michelle Sholzberg, @sholzberg.

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