Low-cost blood drug saves thousands of trauma patients’ lives

Tranexamic acid is now recommended by NICE and international guidelines and is estimated to annually save around 400 lives in the UK and over 100,000 lives worldwide. 

Giving an old drug a new purpose among trauma victims

Bleeding is a major cause of death among trauma victims. Around 20,000 people in the UK sustain major trauma injuries every year. For those who survive to reach hospital, over a quarter still die from blood loss. 

Trauma also comes at a cost to society. Treating trauma injuries costs the NHS between £300 million and £400 million each year, while every trauma death costs the UK economy £750,000.

To save more lives after trauma, an effective treatment to control bleeding was essential. One approach was tranexamic acid – a low-cost treatment that is widely used to reduce bleeding during surgery. With £2.5 million NIHR funding, a research team from the London School of Hygiene and Tropical Medicine put tranexamic acid to the test among trauma patients in the CRASH-2 trial.

Led by Ian Roberts, Professor of Epidemiology and Public Health, the trial involved just over 20,000 bleeding trauma victims from hospitals across 40 countries. Patients received either a tranexamic acid injection or placebo as soon as possible after the trauma. 

Shaping the global use of life-saving tranexamic acid

The CRASH-2 trial’s results, published in The Lancet, showed that nearly 2 in every 10 trauma deaths could be prevented by tranexamic acid treatment within 3 hours of injury. This meant that around 400 lives and up to £544 million could be saved in the UK each year. Worldwide, over 100,000 lives could be saved. 

The CRASH-2 trial led to a worldwide change in treatment practices, with tranexamic acid regarded as the best standard of care for severe injury. In 2010, tranexamic acid was included on the World Health Organization's list of essential medicines.

In England, the 2016 NICE guideline on major trauma recommended that trauma patients receive tranexamic acid within 3 hours of injury. By the end of 2016, 9 out of 10 patients with severe injury received tranexamic acid, compared with nearly 0 in 2010. 

The British and US Armies also included tranexamic acid in their combat care treatment guidelines. In 2019, the government invested £5 million to develop a tranexamic acid autoinjector. Injured soldiers will use this kit to self-inject tranexamic acid while they wait for medical help.

Professor Roberts explained how the results continue to drive wider tranexamic acid use, saying: “The recent Manchester Arena Bombing Inquiry report (2022) gave further impetus to UK efforts to use tranexamic acid, and recommended that paramedics give tranexamic acid by intramuscular injection to save time in a mass casualty event.” Further work by Professor Roberts’ team had shown that an intramuscular injection of tranexamic acid is effective.

The NHS ambulance service policy was updated in 2023 to reflect the inquiry’s recommendations. Professor Roberts is also part of an NHS group that promotes the use of intramuscular tranexamic acid by UK paramedics.

Driving medical advances through research 

CRASH-2’s practice-changing results paved the way for a new NIHR-funded trial, CRASH-3. Supported by a £1.2 million award, CRASH-3 investigated whether early treatment with tranexamic acid reduced deaths from traumatic head injury. Head trauma affects around 40,000 people in the UK and 69 million worldwide each year. 

CRASH-3 involved 12,000 head injury patients from 175 hospitals worldwide, including 3,000 UK patients recruited by the NIHR’s Clinical Research Network. Published in The Lancet, CRASH-3 gave the first clear evidence that tranexamic acid reduces head injury deaths by 20%. “This was an important breakthrough and the first neuroprotective drug for patients with head injury,” said Professor Roberts. 

With £3 million NIHR funding, the ongoing CRASH-4 trial is investigating the role of tranexamic acid in preventing death and disability among older adults with mild head injuries.

The CRASH-2 study was funded by the NIHR Health Technology Assessment Programme and published in Health Technology Assessment.