Page 41 - Haematologica May 2020

The never ending success story of tranexamic acid in acquired bleeding
Ferrata Storti Foundation
Haematologica 2020 Volume 105(5):1201-1205
Massimo Franchini1 and Pier Mannuccio Mannucci2
1Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova and 2Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
ABSTRACT
Tranexamic acid (TXA) is an anti-fibrinolytic agent that acts by inhibiting plasminogen activation and fibrinolysis. Although its first clinical use dates back more than 50 years, this hemostatic agent is still the object of intense clinical and developmental research. In particular, renewed interest in TXA has arisen following evidence that it has a beneficial effect in reducing blood loss in a variety of medical and surgical conditions at increased risk of bleeding. Given this characteristic, TXA is currently considered a mainstay of Patient Blood Management programs aimed at reducing patients’ exposure to allogeneic blood trans- fusion. Importantly, recent large randomized controlled trials have consis- tently documented that the use of TXA confers a survival advantage in a number of globally critical clinical conditions associated with acute bleed- ing, including traumatic injury and post-partum hemorrhage, without increasing the thromboembolic risk.
Introduction
Tranexamic acid (TXA) is a synthetic anti-fibrinolytic amino acid derivative of lysine that acts by competitively blocking the lysine binding sites on plasminogen, thereby inhibiting its interaction with formed plasmin and fibrin.1,2 Inhibition of plasminogen activation results in the stabilization of the preformed fibrin mesh- work produced by the coagulation cascade. Thanks to its ability to inhibit fibri- nolysis and clot degradation TXA, which is approved for intravenous, oral and topical applications, has been successfully employed to prevent or decrease blood loss in a variety of clinical conditions characterized by excessive bleeding.3,4 There is indeed consistent evidence that the early administration of TXA confers a sur- vival benefit in the setting of severe trauma5,6 and post-partum hemorrhage with- out an increase in thromboembolic events.7 In addition, this agent has been suc- cessfully used to decrease blood loss in numerous surgical specialties, especially in the frame of cardiac and major orthopedic surgery.8-11 For this reason, TXA is cur- rently considered a fundamental pillar of the Patient Blood Management (PBM) programs of transfusion medicine, aimed at minimizing blood loss and thus expo- sure of patients undergoing elective surgery to allogeneic blood.12-14 In this narra- tive review we summarize the most recent clinical evidence on the use of TXA for prevention or treatment of bleeding.
Search methods
We analyzed the medical literature for published articles on the use of TXA for bleeding. The MEDLINE electronic database was searched for publications during the last 20 years using English language as a restriction. The Medical Subject Heading and key words used were: “tranexamic acid”, “bleeding”, “hemorrhage”, “treatment”, “prevention”, “patient blood management”, “anti-fibrinolytic”, “surgery”, “cardiac surgery”, “orthopedic surgery”, “post-partum hemorrhage”, “obstetric”, “trauma”, “injury” and “traumatic brain injury”. We also screened the reference lists of the most relevant review articles for additional studies not cap- tured in our initial literature search. Finally, abstracts from relevant conferences or scientific meetings were hand-searched for additional studies.
Correspondence:
PIER MANNUCCIO MANNUCCI
piermannuccio.mannucci@policlinico.mi.it
Received: March 3, 2020. Accepted: March 16, 2020. Pre-published: March 26, 2020.
doi:10.3324/haematol.2020.250720
Check the online version for the most updated information on this article, online supplements, and information on authorship & disclosures: www.haematologica.org/content/105/5/1201
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