Tranexamic Acid and Trauma

I recently received a request to write about tranexamic acid (TXA) and trauma patients. There is a lot of interest in this agent, especially in the military, and there are some good, recent papers to review.

Tranexamic acid works differently than the quick clotting agents out there. It is an antifibrinolytic, so it actually prevents clot breakdown. It has been approved by the FDA for use in hemophiliacs undergoing dental work and for menorrhagia. Thrombotic complications have been described, so it cannot be used with prothrombin complex concentrate or recombinant activated factor VII.

The most recent and best known study on TXA is the CRASH-2 study. It was extremely well designed and included over 20,000 patients in hospitals spanning 40 countries. The study design has survived serious scrutiny. They found that TXA use in trauma patients reduced the relative risk of death by 9% (from 16% to 14.5%). The risk of death specifically from bleeding was reduced by 15%. And use of TXA in the most severely injured patients, those who would die of bleeding on the day of randomization, was reduced by 20%. There were no adverse events or differences in thrombotic events, including deep venous thrombosis.

Bottom line: TXA has been shown to be effective, safe and inexpensive (about $200 for treatment using retail pricing). It is the only drug that has been shown to reduce all-cause mortality from bleeding in a high quality trial. It has already been adopted by some hospitals in both the US and the UK. CRASH-2 suggested that TXA was of most benefit when given within 3 hours of injury and in patients with a systolic pressure less than or equal to 75 torr. Trauma centers should begin incorporating this important drug into their initial treatment protocols now. However, since it’s not FDA approved in the USA, we will need to wait a while and watch everybody else.

Final thought: Will this eventually be started by EMS?

Reference: Tranexamic acid for trauma patients: a critical review of the literature. J Trauma 71(1):S9-S14, 2011.

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