Tranexamic acid vs. epsilon-aminocaproic acid: Evidence gaps and practical implications

TXA vs. EACA: Evidence and practice

Abstract

Antifibrinolytic agents, particularly tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), are widely used to reduce perioperative bleeding. Although both drugs share a similar mechanism—competitive inhibition of plasminogen activation—they differ in pharmacologic potency, dosing requirements, and clinical evidence. TXA demonstrates 6–10 times greater affinity for plasminogen, resulting in stronger antifibrinolytic effects at lower doses. Evidence from randomized trials and meta-analyses, primarily in orthopedic surgery, suggests TXA may reduce blood loss more effectively than EACA; however, differences in transfusion rates and thromboembolic complications are generally not significant. In cardiac surgery, limited data show no clear superiority of either agent.  TXA has robust evidence supporting its use in trauma and obstetrics, while comparable high-quality data for EACA remain lacking. Both agents appear safe, though high doses—especially in renal impairment—may increase seizure risk. Importantly, EACA may achieve similar clinical outcomes when administered at appropriately higher doses.  Current evidence is limited by heterogeneous study designs, variable dosing regimens, and underpowered trials. Overall, while TXA is more potent and better studied, definitive clinical superiority over EACA remains unproven. Drug selection should therefore consider patient factors, institutional protocols, and resource availability pending further large-scale comparative trials.