What is the recommended dosing for tranexamic acid (TXA)?

From the Guidelines

The recommended dosing for tranexamic acid (TXA) is 1 gram IV over 10 minutes, followed by 1 gram IV over 8 hours, as soon as possible, if feasible en route to the hospital, and within 3 h after injury. This dosing regimen is based on the most recent and highest quality study, which recommends the administration of TXA to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible 1. The study suggests that the administration of TXA should not await results from a viscoelastic assessment and should be given within 3 hours of injury.

Indications and Dosage

• For trauma and significant hemorrhage, the standard dose is 1 gram IV over 10 minutes, followed by 1 gram IV over 8 hours 1.
• For post-partum haemorrhage, the recommended dose is 1 g (100 mg/mL) intravenously at 1 mL/min, with a second dose of 1 g intravenously if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose 1.
• Renal dosing adjustments are necessary for patients with kidney impairment, although the exact adjustments are not specified in the provided studies.

Mechanism of Action and Side Effects

• TXA works as an antifibrinolytic by binding to plasminogen and blocking its conversion to plasmin, thereby preventing clot breakdown and reducing bleeding.
• Common side effects include nausea, vomiting, and hypotension with rapid IV administration, while seizures are a rare but serious concern at high doses.

Clinical Considerations

• The administration of TXA should be planned and protocols for the management of bleeding patients should consider administration of the first dose of TXA en route to the hospital or at the pre-hospital site of injury.
• The cost-effectiveness of TXA in trauma has been calculated in several countries, and the estimated incremental cost per life year gained of administering TXA is relatively low 1.

From the FDA Drug Label

1. DOSAGE & ADMINISTRATION 2.1 Recommended Dosage The recommended dose of tranexamic acid injection is 10 mg/kg actual body weight intravenously administered as a single dose, immediately before tooth extractions. Infuse no more than 1 mL/minute to avoid hypotension [see WARNINGS AND PRECAUTIONS (5. 1)]. Following tooth extraction, tranexamic acid injection may be administered for 2 to 8 days at a dose of 10 mg/kg actual body weight 3 to 4 times daily, intravenously.

The recommended dosing for tranexamic acid (TXA) is:

• 10 mg/kg actual body weight intravenously as a single dose before tooth extractions
• 10 mg/kg actual body weight 3 to 4 times daily, intravenously, for 2 to 8 days after tooth extraction
• Dose reduction is recommended for patients with moderate to severe impaired renal function 2 Key points to consider:
• Infuse no more than 1 mL/minute to avoid hypotension
• Do not mix with blood or solutions containing penicillin

From the Research

Tranexamic Acid Dosing

• The recommended dosing for tranexamic acid (TXA) varies depending on the clinical context.
• In trauma patients, a loading dose of 1 g over 10 min followed by an infusion of 1 g over 8 h has been shown to safely reduce mortality 3.
• For post-partum haemorrhage, the WHO recommends 1 g TXA intravenously as soon as possible after giving birth, followed by a second dose if bleeding continues after 30 min or restarts within 24 h since the first dose 4.
• The pharmacokinetics of TXA have been studied in healthy volunteers, with oral and intramuscular bioavailabilities of 46 and 105%, respectively 5.
• A systematic review of pharmacodynamics studies suggests that TXA concentrations between 10 and 15 mg/l may be suitable targets for inhibiting fibrinolysis, although concentrations between 5 and 10 mg/l may also be effective 6.
• A comparative analysis of TXA dosing strategies in traumatic major hemorrhage found that clinical outcomes were equivalent across three different dosing strategies: 1 g bolus only, 1 g bolus + 1 g infusion over 8 hours, and 2 g bolus 7.

Dosing Strategies

• Single bolus administration of TXA may be preferable to a bolus plus infusion regimen in traumatic major hemorrhage 7.
• The choice of dosing strategy may depend on the specific clinical context and the severity of bleeding.
• Further research is needed to determine the optimal dosing regimen for TXA in different clinical settings.

Key Considerations

• Early administration of TXA is critical in reducing mortality and morbidity in bleeding patients 3, 4.
• The effectiveness of TXA in inhibiting fibrinolysis may depend on the concentration achieved in the blood 6.
• Different routes of administration, such as oral and intramuscular, may be useful in specific circumstances, but further research is needed to establish their efficacy and safety 5.