What is the role of Tranexa (tranexamic acid) in preventing or treating excessive blood loss in cancer patients, particularly those with a high risk of bleeding?

Tranexamic Acid in Cancer Patients: Limited Role with Important Caveats

Tranexamic acid should NOT be used routinely in cancer patients for bleeding prevention or treatment, with the exception of specific surgical scenarios where massive blood loss is anticipated. The evidence demonstrates no benefit in hematological malignancies with thrombocytopenia, potential harm in cancer-associated DIC, and insufficient data in solid tumor bleeding 1, 2, 3.

Cancer-Associated DIC: Avoid Routine Use

• Tranexamic acid is explicitly NOT recommended for routine use in cancer-associated disseminated intravascular coagulation (DIC) and may be deleterious in non-hyperfibrinolytic types 1.
• The International Society on Thrombosis and Haemostasis states that while antifibrinolytic agents were historically advocated for acute promyelocytic leukemia (APL) before all-trans retinoic acid became standard, a large retrospective study showed no significant benefit in reducing early hemorrhagic deaths 1.
• The PETHEMA group found no clear advantage in reducing hemorrhagic incidents with systematic tranexamic acid prophylaxis in APL induction therapy, but noted a trend toward higher thrombotic events 1.
• Tranexamic acid may only be considered in hyperfibrinolytic DIC when therapy-resistant bleeding dominates the clinical picture, but this is a last-resort measure after all other interventions have failed 1.

Hematological Malignancies with Thrombocytopenia: No Benefit Demonstrated

• The most recent and highest quality evidence from the 2025 TREATT trial (616 patients) and subsequent meta-analysis (946 patients) conclusively demonstrates that tranexamic acid does NOT reduce bleeding or platelet transfusion requirements in patients with hematological malignancies undergoing intensive chemotherapy or stem cell transplantation 2, 3.
• The TREATT trial showed no difference in WHO grade ≥2 bleeding between tranexamic acid (31.7%) and placebo (34.2%) groups (hazard ratio 0.92; 95% CI 0.67-1.27; p=0.62) 2.
• Trial sequential analysis indicates the current evidence is conclusive and suggests futility of additional trials—meaning further research is unlikely to change this recommendation 3.
• There was no reduction in the mean number of platelet transfusions per participant (standardized mean difference 0.00; 95% CI -0.12 to 0.13) 3.
• Safety outcomes showed no increased risk of thrombotic events, veno-occlusive disease, or all-cause mortality, but also no benefit to justify routine use 2, 3.

Solid Tumor Surgery: Insufficient Evidence

• For cytoreductive surgery in advanced ovarian cancer, a single RCT (100 patients) showed no clinically important reduction in blood loss with tranexamic acid 15 mg/kg IV given immediately before surgery (mean difference -248.59 mL; 95% CI -550.9 to 53.79) 4.
• The Cochrane review concluded there is insufficient evidence to recommend routine use of tranexamic acid for reducing blood loss in women undergoing cytoreductive surgery for advanced epithelial ovarian cancer 4.
• The quality of evidence was downgraded due to baseline characteristic imbalances and lack of standardized blood transfusion protocols across participating hospitals 4.

Palliative Care Bleeding: Case Reports Only

• Evidence for tranexamic acid in palliative care cancer patients consists only of case reports, not controlled trials 5.
• One case series reported successful bleeding control with 1000 mg IV three times daily for 2-3 days, followed by 3000 mg oral daily as maintenance, but this represents very low-quality evidence 5.
• The authors themselves acknowledge that general dosing recommendations are unclear and further studies are needed for evidence-based information 5.

When Tranexamic Acid MAY Be Appropriate in Cancer Patients

Tranexamic acid can be considered in cancer patients only in the following specific scenarios:

• Major cancer surgery with anticipated massive blood loss (e.g., extensive pelvic exenteration, hepatobiliary resections), using standard trauma dosing: 1g IV over 10 minutes followed by 1g infusion over 8 hours 1, 6.
• Postoperative bleeding in cancer patients when excessive bleeding occurs after surgery, administered within 3 hours of bleeding onset for maximum efficacy 6.
• Therapy-resistant bleeding in hyperfibrinolytic DIC as a last resort when all other measures have failed 1.

Critical Safety Considerations in Cancer Patients

• Cancer patients often have baseline hypercoagulability, making the thrombotic risk profile different from trauma or surgical patients 7.
• The PETHEMA group's observation of increased thrombotic events with tranexamic acid in APL patients highlights this concern 1.
• Renal impairment is common in cancer patients (from tumor, chemotherapy, or sepsis), requiring dramatic dose reduction to 10 mg/kg every 48 hours maximum to prevent neurotoxicity and seizures 8.
• Patients with active intravascular clotting or DIC should never receive tranexamic acid as it may worsen the condition 1, 9.

Algorithm for Decision-Making

1. Identify the bleeding scenario:

   • Cancer-associated DIC → Do NOT use tranexamic acid routinely 1
   • Hematological malignancy with thrombocytopenia → Do NOT use tranexamic acid 2, 3
   • Planned major cancer surgery → Consider use with standard dosing 1
   • Palliative care bleeding → Insufficient evidence; consider only after other measures fail 5

2. If considering use in surgery, screen for contraindications:

   • Active thrombosis or history of thromboembolism → Contraindicated 9
   • DIC or active intravascular clotting → Contraindicated 1, 9
   • Severe renal impairment → Reduce dose dramatically 8

3. If proceeding with tranexamic acid:

   • Administer 1g IV over 10 minutes before incision 6, 8
   • Follow with 1g infusion over 8 hours for procedures exceeding 2-3 hours 6
   • Ensure administration within 3 hours of bleeding onset if treating active hemorrhage 6

Common Pitfalls to Avoid

• Do not use tranexamic acid as a substitute for definitive cancer treatment in cancer-associated DIC; treating the underlying malignancy is the first-line strategy 1.
• Do not assume tranexamic acid will reduce platelet transfusion requirements in hematological malignancies—the evidence conclusively shows it does not 2, 3.
• Do not use high-dose tranexamic acid (≥4g/24h) in critically ill cancer patients with gastrointestinal bleeding, as this increases DVT, PE, and seizure risk without mortality benefit 6.
• Do not administer tranexamic acid after 3 hours of bleeding onset, as efficacy is lost and potential harm may increase 6.