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Tranexamic Acid for Acute Hemorrhage: A Narrative Review of Landmark Studies and a Critical Reappraisal of Its Use Over the Last Decade

Lier, Heiko MD*; Maegele, Marc MD; Shander, Aryeh MD

doi: 10.1213/ANE.0000000000004389
Continuing Medical Education

The publication of the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study and its intense dissemination prompted a renaissance for the use of the antifibrinolytic agent tranexamic acid (TXA) in acute trauma hemorrhage. Subsequent studies led to its widespread use as a therapeutic as well as prophylactic agent across different clinical scenarios involving bleeding, such as trauma, postpartum, and orthopedic surgery. However, results from the existing studies are confounded by methodological and statistical ambiguities and are open to varied interpretations. Substantial knowledge gaps remain on dosing, pharmacokinetics, mechanism of action, and clinical applications for TXA. The risk for potential thromboembolic complications with the use of TXA must be balanced against its clinical benefits. The present article aims to provide a critical reappraisal of TXA use over the last decade and a “thought exercise” in the potential downsides of TXA. A more selective and individualized use of TXA, guided by extended and functional coagulation assays, is advocated in the context of the evolving concept of precision medicine.

From the *Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany

Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany

Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine, Englewood Health, TeamHealth Research Institute, Englewood, New Jersey.

Published ahead of print 3 September 2019.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Heiko Lier, MD, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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