Tranexamic Acid for Hemostasis and Beyond

Tranexamic acid (TXA), a synthetic lysine analogue, is an effective antifibrinolytic agent widely used for controlling excessive bleeding. Introduced in the 1960s, TXA competitively inhibits plasminogen activation, stabilizing fibrin clots. Large randomized trials, including CRASH-2 (trauma) and WOMAN (obstetric hemorrhage), demonstrated reduced mortality when TXA is administered early, within three hours of bleeding onset. Consequently, TXA is recommended globally for severe trauma and postpartum hemorrhage. It is also widely employed perioperatively in cardiac and orthopedic surgery, significantly reducing blood loss and transfusion requirements. In congenital bleeding disorders such as hemophilia and von Willebrand disease, TXA effectively controls mucosal and procedural bleeding alongside standard therapies. However, routine TXA use in spontaneous intracranial hemorrhage or gastrointestinal bleeding is unsupported due to insufficient evidence and potential thrombotic risks. Recent studies suggest TXA possesses additional benefits beyond hemostasis, including anti-inflammatory and immunomodulatory effects, neuroprotection in traumatic brain injury and stroke, muscle regeneration promotion, and therapeutic potential in hereditary angioedema (HAE). TXA modulates inflammation via inhibition of plasminmediated complement activation, reduces neuronal apoptosis, supports muscle tissue repair through extracellular matrix remodeling, and reduces bradykinin generation in HAE patients. TXA generally exhibits an excellent safety profile, though caution for patients at elevated thrombotic risk or impaired renal function. Further research into patient selection and individualized dosing strategies is warranted. This review summarizes TXA’s mechanisms, diverse clinical applications, dosage recommendations, therapeutic outcomes, and safety considerations to support evidence-based practice.