Older drug could slash blood transfusions during surgeries | ASH 2025

The use of an older medication at the time of surgery can reduce the need for red blood cell transfusions, according to a late-breaking presentation at the 67th American Society of Hematology (ASH) Annual Meeting being held in Orlando.

The positive findings of a study on the use of tranexamic acid have implications both for the patient as well as the healthcare system, said Brett Houston, M.D., Ph.D., an assistant professor in the department of Internal Medicine at the University of Manitoba and a clinical investigator at CancerCare Manitoba, who presented the data.

“If there are approximately 100 million inpatient noncardiac surgeries each year, administering this medication broadly has the potential to reduce exposure to perioperative red blood cell transfusions in 1 million to 2 million people each year,” she said during a press briefing. “Further, it could potentially mitigate 5 million to 10 million units of perioperative red cell transfusions. Tranexamic acid, importantly, did not increase venous thromboembolism or blood clots, even among patients with cancer who had particularly increased risk.”

Blood transfusions are common, with a total of 21 million blood components transfused each year in the United States, according to the American Red Cross. Transfusions are given during injuries when there is significant blood loss, for those with sickle cell disease and to those with cancer.

Blood transfusions are also given during and after surgical procedures to keep patients stable, to replace blood lost, to correct anemia, and maintain clotting. With today’s safety protocols, transfusion is generally safe but is not without risk. There is a risk of fever, rashes, allergic reactions, and can be associated with waste.

Additionally, the blood supply continues to be low. Last year, officials with the American Red Cross said there was an emergency blood shortage, and hospitals around the country continue to face low supplies.

Houston and her colleagues wanted to assess whether the use of tranexamic acid could decrease the use of blood transfusions without increasing the risk of thrombosis.

Tranexamic acid is a drug that has been available for more than 50 years and is used to stop bleeding and prevent clots. Its only approved indication is for heavy menstrual bleeding and short-term prevention in patients with hemophilia. But it has been used off-label in trauma situations and some surgeries. Tranexamic acid is available both orally and for intravenous administration.

Houston said tranexamic acid is inexpensive, widely available, and has an established side effect profile. “It’s been shown to reduce transfusion in the context of cardiac surgery, orthopedic surgery, trauma and postpartum hemorrhage,” she said. “Prior trials have evaluated tranexamic acid in the context of noncardiac surgery, although uptake has been somewhat limited due to residual concerns of thrombosis.”

Houston and her colleagues conducted a trial, called TRACTION, to evaluate the impact of a hospital-wide policy of tranexamic acid use among people undergoing noncardiac surgeries. The trial was a multicenter, randomized, placebo-controlled cluster crossover trial and recruited patients from 10 hospitals across Canada from February 2022 to 2024. Sites were randomly allocated to provide tranexamic acid to patients undergoing high-risk noncardiac surgery in a one-to-one ratio at four weekly intervals.

The study included about 8,300 patients. Researchers followed patients to assess thrombotic outcome for 90 days, which is the period of increased risk, and they prioritized a patient population with oncology or cancer patients who are at particularly increased risk for thrombosis. Included in the study were eligible adult patients undergoing major noncardiac surgery. This included open surgeries as well as laparoscopic surgeries of three or more hours duration.

Tranexamic acid was administered as a one-gram bolus at the start of surgery, followed by an additional one gram prior to skin closure that was administered at the discretion of the treating anesthesiologist.

Researchers found that the proportion of patients who required transfused red blood cells during hospital admission was 7.4% in the tranexamic acid arm and 9.8% in the placebo arm, which Houston said equates to a 2.4% absolute risk reduction.

Additionally, the proportion of patients diagnosed with venous thromboembolism within 90 days was 2.1% in the tranexamic acid arm and 2.1% in the placebo arm. There was no difference in hospital diagnoses of myocardial infarction, stroke, deep vein thrombosis, or pulmonary embolism. Similarly, there was no difference in ICU admission, hospital length of stay, hospital survival, or overall survival to day 90.

“The novel methods used in TRACTION — a cluster, crossover design with limited manual data capture and an electronic registry — enabled us to conduct the trial at a fraction of the cost that it would typically take using traditional methods,” Houston said. “We’ve demonstrated that large, high-quality, practice-changing, and cost-effective trials can be conducted using routinely collected data.”