Red Blood Cells and Tranexamic Acid in the Inhibition of Fibrinolysis

Tranexamic acid (TXA) is a widely used and cost-effective antifibrinolytic agent that has been utilized for decades in various clinical situations involving bleeding complications. Over time, a growing amount of clinical evidence has emerged, offering a robust basis for its applications.

However, in certain clinical scenarios, TXA appears to be less effective, highlighting the need for further research into its mechanisms of action beyond its well-known antifibrinolytic effects. One area of particular interest is the interaction between TXA and blood cells, especially red blood cells (RBCs). This interaction has garnered significant attention due to intriguing findings from large clinical trials, such as the WOMAN-1 and -2 studies, which evaluated the efficacy of TXA in preventing bleeding in postpartum hemorrhage, a major childbirth complication. These trials revealed that TXA was less effective in anemic patients, raising important questions about its broader mechanisms of action.

Emerging evidence suggests that the relationship between TXA and blood cells plays a crucial role at various stages of hemostasis, expanding its established role in fibrinolysis inhibition. Recent investigations into the interactions between TXA and RBCs have been particularly compelling and may provide valuable insights for improving clinical outcomes.

This review provides a fresh look at the interplay between RBCs, TXA, and the hemostatic system, focusing on basic molecular mechanisms and their potential implications for clinical practice.