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Received: 12 March 2021    Revised: 23 April 2021    Accepted: 27 April 2021

DOI: 10.1002/rth2.12546

I L L U S T R AT E D R E V I E W

Tranexamic acid evidence and controversies: An illustrated

review

Nicole Relke MD1  | Nicholas L. J. Chornenki MD1  |

Michelle Sholzberg MDCM, MSc, FRCPC2,3,4

1
Department of Medicine, Queen's
University, Kingston, ON, Canada Abstract
2
Department of Medicine, St. Michael's Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment
Hospital, University of Toronto, Toronto,
ON, Canada
or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual
3
Department of Laboratory Medicine bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site
& Pathobiology, St. Michael's Hospital, bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA
University of Toronto, Toronto, ON,
Canada persists in many clinical settings. This illustrated review describes the history, phar-
4
Division of Hematology, Department macology, and practical considerations of TXA use. We also describe the major land-
of Medicine, St. Michael's Hospital,
mark randomized controlled trials of TXA and their implications. Finally, we review the
University of Toronto, Toronto, ON,
Canada evidence around common controversies surrounding TXA such as the risk of throm-
bosis, prescription along with combined hormonal contraceptives, and use in patients
Correspondence
Nicole Relke, Department of Medicine, with gross hematuria.
Queen’s University, Kingston, ON,
Canada.
KEYWORDS
Email: nrelke@qmed.ca
antifibrinolytic agents, blood coagulation, contraceptive agents, thrombosis, tranexamic acid
Handling Editor: Alisa Wolberg.

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.

This is an open access article under the terms of the Creat​ive Commo​ns Attri​butio​n-­NonCo​mmerc​ial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2021 The Authors. Research and Practice in Thrombosis and Haemostasis published by Wiley Periodicals LLC on behalf of International Society on Thrombosis
and Haemostasis (ISTH).

Res Pract Thromb Haemost. 2021;5:e12546.  |

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T X A I LLU S TR ATE D R E V I E W
1-­74
Reference citations
AC K N OW L E D G M E N T S
Select images in this review were taken from https://smart.servi​
er.com and are licensed under a Creative Commons Attribution 3.0
Unported License. Blood drop image (pages 1, 4-­5, 9-­11) was pur-
chased from shutterstock (stock vector ID: 641207020)
R E L AT I O N S H I P D I S C LO S U R E
The authors declare no conflicts of interest.
AU T H O R C O N T R I B U T I O N S
NR and MS conceived and designed the manuscript. NR, NLJC, and
MS wrote the paper.
ORCID
Nicole Relke  https://orcid.org/0000-0003-3416-6765
RELKE et al. |
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How to cite this article: Relke N, Chornenki NLJ, Sholzberg
M. Tranexamic acid evidence and controversies: An
illustrated review. Res Pract Thromb Haemost. 2021;5:e12546.
https://doi.org/10.1002/rth2.12546