UK Clinical Pharmacy Association

Tranexamic acid

Issues for surgery

For local fibrinolysis – risk of localised haemorrhage if omitted.

For menorrhagia – risk of increased menstrual bleeding if omitted during menstruation.

For hereditary angioedema/angioneurotic oedema – risk of uncontrolled angioedema which may lead to significant airway compromise and a requirement for invasive intubation if omitted (see Further information).

For epistaxis – risk of haemorrhage and/or increased requirement for blood transfusion if omitted.

For general fibrinolysis (IV) – risk of haemorrhage and/or increased requirement for blood transfusion if omitted.

For prevention and treatment of significant haemorrhage following trauma – risk of haemorrhage and/or increased requirement for blood transfusion if omitted.

Risk of venous thromboembolism (VTE) if continued without adequate VTE risk assessment.

Advice in the perioperative period

Elective surgery 


Patients with hereditary angioedema

Tranexamic acid can be used as short-term prophylaxis of hereditary angioedema in patients undergoing planned procedures. It should be administered several days pre-operatively and continued for 2 – 5 days post-operatively. Advice should be sought from an Immunologist to plan for elective procedures (see Further information).

Patients with haemophilia

Tranexamic acid may be used perioperatively to reduce the risk of bleeding in patients with haemophilia undergoing surgical procedures. Advice should be sought from a haematologist who should be involved in the pre-operative planning for the patient.

Emergency surgery 

Continue, or consider initiation for prevention or treatment of major haemorrhage following major trauma or for patients admitted with upper gastrointestinal bleeding (see British National Formulary for details).

Patients with hereditary angioedema

Advice should be sought from an immunologist (see Further Information).

Patients with haemophilia

Advice should be sought from a haematologist.

Perioperative considerations

Tranexamic acid should be considered in all adults having major surgery to reduce operative bleeding – see Further information.

Post-operative advice

Review indication as early as possible and continue only if still required.

If to continue for an underlying indication, ensure a clear plan is documented.

Ensure adequate thromboprophylaxis in patients with increased risk of thrombosis, i.e., taking combined oral contraceptives, history of thromboembolic event. Ensure appropriate venous thromboembolic (VTE) risk assessment is completed to assess the risks and benefits of both mechanical and pharmacological thromboprophylaxis. See Further information.

Monitor renal function post-operatively since there is a risk of accumulation if renal impairment occurs and repeated doses of tranexamic acid are given.

Interactions with common anaesthetic agents


Interactions with other common medicines used in the perioperative period


Further information

Surgical bleeding

The POISE-3 (Peri-Operative Ischaemic Evaulation-3) trial found that tranexamic acid reduces major bleeding by approximately 25% and significantly reduces blood transfusion. Other reviews of tranexamic use have found that it reduced perioperative blood loss and transfusion requirement in a variety of surgical disciplines. The Royal College of Obstetrics and Gynaecology (RCOG) recommends that tranexamic acid should be consider at caesarean section to reduce blood loss in women at increased risk of post-partum haemorrhage (PPH). Current recommendation is that tranexamic acid should be considered in all adults having major surgery or at significant risk of bleeding to reduce operative bleeding.

Venous thromboembolism

Most randomised trials do not indicate an increased risk of thrombotic events in patients receiving tranexamic acid, however some trials have reported an increased rate of thrombotic complications. In the POISE-3 trial, due to statistical power, it was almost impossible to detect a small increase or decrease in the risk of thrombosis with tranexamic acid. Ongoing vigilance for the risk of thrombotic events is needed; however, because bleeding associated with surgery is common and thromboembolic events comparatively rare, the balance of benefits and risk favours use of tranexamic acid perioperatively.

Tranexamic use for prophylaxis of hereditary angioedema

If surgery or dental work is to be carried out on a planned basis, use of tranexamic acid commenced 5 days before the procedure and continued for 2 days after can be used. The usual dose is 1g four times a day in adults.


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Devereaux PJ, Marcucci MD, Painter MB et al. Tranexamic Acid in Patients Undergoing Noncardiac Surgery. N Engl J Med 2022;386:1986-1997. DOI: 10.1056/NEJMoa2201171

Heyns M, Knight P, Steve AK et al. A Single Preoperative Dose of Tranexamic Acid Reduces Perioperative Blood Loss: A Meta-analysis. Ann Surg. 2021; 273(1):75-81. DOI: 10.1097/SLA.0000000000003793

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Murphy M, Roberts I, Sayers R et al. Tranexamic acid for safer surgery: the time is now. The UK Royal Colleges Tranexamic in Surgery Implementation Group. British Journal of Anaesthesia. 2022; 129(4):459-461. DOI: 10.1016/j.bja.2022.06.024