Is tranexamic acid (TXA) safe to use in a trauma patient on aspirin (acetylsalicylic acid) due to a history of stroke?

From the Guidelines

Tranexamic acid (TXA) can generally be safely administered to trauma patients who are on aspirin therapy for stroke prevention, as the benefits of TXA in reducing mortality in bleeding trauma patients typically outweigh the theoretical concerns about combining it with antiplatelet therapy like aspirin. The standard TXA dosing for trauma is 1 gram IV over 10 minutes, followed by 1 gram infused over 8 hours, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. While both medications affect different aspects of hemostasis—TXA inhibits fibrinolysis (clot breakdown) while aspirin inhibits platelet aggregation—they do not directly interact in a way that significantly increases bleeding risk. In fact, TXA may help counterbalance some of the bleeding risk associated with aspirin therapy. However, clinical judgment is still important, as each patient's overall coagulation status, injury severity, and comorbidities should be considered. Patients should be monitored for signs of thrombotic complications, though the risk of these events is relatively low when TXA is used appropriately in the acute trauma setting, as shown in the CRASH-2 trial 2.

Some key points to consider when administering TXA to trauma patients on aspirin therapy include:

• The importance of early administration of TXA, as it has been shown to reduce the risk of death due to bleeding when given within 3 hours of injury 2
• The need for clinical judgment in each patient's case, taking into account their individual coagulation status, injury severity, and comorbidities
• The potential benefits of TXA in counterbalancing the bleeding risk associated with aspirin therapy
• The relatively low risk of thrombotic complications when TXA is used appropriately in the acute trauma setting 2

Overall, the use of TXA in trauma patients on aspirin therapy for stroke prevention is supported by the available evidence, and the benefits of TXA in reducing mortality in bleeding trauma patients typically outweigh the theoretical concerns about combining it with antiplatelet therapy like aspirin.

From the FDA Drug Label

Tranexamic acid injection is an antifibrinolytic indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction In patients with subarachnoid hemorrhage, due to risk of cerebral edema and cerebral infarction. Prothrombotic Medical Products: Avoid concomitant use, can further increase the risk of thromboembolic adverse reactions associated with tranexamic acid.

The use of tranexamic acid in a trauma patient on aspirin due to a history of stroke is not directly addressed in the provided drug labels. However, considering the patient's history of stroke and the contraindication of tranexamic acid in patients with subarachnoid hemorrhage, there may be an increased risk of cerebral edema and cerebral infarction. Additionally, the concomitant use of aspirin (a prothrombotic medical product) with tranexamic acid may further increase the risk of thromboembolic adverse reactions.

• The patient's history of stroke and current use of aspirin should be carefully considered before administering tranexamic acid.
• The potential benefits of using tranexamic acid in this patient should be weighed against the potential risks of thromboembolic events and cerebral complications.
• It is recommended to exercise caution when considering the use of tranexamic acid in this patient population 3, 4.

From the Research

Safety of Tranexamic Acid in Trauma Patients on Aspirin

• The use of tranexamic acid (TXA) in trauma patients, including those on aspirin due to a history of stroke, is a topic of interest in the medical field 5, 6.
• TXA is an antifibrinolytic agent that prevents traumatic exsanguination by competitively inhibiting plasminogen activation, thereby reducing conversion of plasminogen into plasmin and preventing fibrinolysis 5.
• Studies have shown that TXA is effective and safe to use in the prehospital setting, with a recommended loading dose of 1 g followed by 1 g infusion over 8 hours, given by intravenous administration within a 3-hour window period of traumatic injury 5.

Considerations for Patients on Aspirin

• Patients on aspirin due to a history of stroke may be at increased risk of bleeding, and the use of TXA in these patients requires careful consideration 6, 7.
• The CRASH-2 trial demonstrated that intravenous administration of TXA improved mortality significantly in trauma patients with significant bleeding, but the risk of vascular occlusive events, such as venous thromboembolisms, must be taken into account 6.
• A systematic review of observational studies found a non-significant increase in the risk of venous thromboembolisms with TXA therapy, highlighting the need for cautious and selective use of TXA in trauma patients 6.

Clinical Applications and Guidelines

• The use of TXA in trauma patients has been widely adopted, but there is ongoing debate about its optimal use, dosing, and potential risks 7, 8.
• A narrative review of landmark studies and a critical reappraisal of TXA use over the last decade highlights the need for a more selective and individualized approach to TXA use, guided by extended and functional coagulation assays 7.
• Clinical guidelines and point-of-care guided utilization of TXA, blood components, and adjunctive hemostatic agents are essential for optimizing outcomes in bleeding trauma patients 8.

Timing of TXA Administration

• TXA has proven mortality benefit if used early after traumatic injury, but its use more than 3 hours after injury may be associated with a significant and paradoxical increased risk of death due to bleeding 9.
• The safety and effectiveness of TXA in polytrauma patients undergoing orthopedic operations outside the 3-hour window of proven trauma efficacy are not well established 9.