What is the recommended dosing regimen for Tranexamic Acid (TXA)?

Tranexamic Acid Dosing Regimen

For trauma patients with significant bleeding or at risk of hemorrhage, tranexamic acid should be administered as a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours, and should be given as early as possible and within 3 hours of injury. 1

Trauma Dosing Protocol

The most recent European guideline (2023) provides a clear recommendation for TXA dosing in trauma:

1. Initial dose: 1 g IV infused over 10 minutes
2. Maintenance dose: 1 g IV infused over 8 hours
3. Timing: As soon as possible, ideally en route to hospital, and within 3 hours of injury
4. Administration: Should not await results from viscoelastic assessment 1

This dosing regimen is supported by high-quality evidence from the CRASH-2 trial, which demonstrated that TXA administration within 3 hours of injury reduces the risk of death due to bleeding by approximately one-third 1.

Critical Timing Considerations

The timing of TXA administration is crucial:

• Administration within 1 hour of injury provides the greatest mortality benefit 1
• Administration between 1-3 hours still provides significant benefit 1
• Administration after 3 hours may increase the risk of death due to bleeding and should be avoided 1

Alternative Dosing Strategies

While the 1 g bolus + 1 g infusion remains the standard recommendation, recent research has explored alternative dosing strategies:

• A 2024 comparative analysis found equivalent clinical outcomes between three dosing strategies: 1 g bolus only, 1 g bolus + 1 g infusion, and 2 g bolus 2
• This suggests that a single bolus administration may be preferable to the bolus plus infusion regimen in some settings 2

Special Populations

Postpartum Hemorrhage

For postpartum hemorrhage, WHO recommends:

• 1 g IV over 10 minutes
• Second dose of 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours 1

Renal Impairment

Dose reduction is recommended for patients with moderate to severe renal impairment 3

Important Considerations

• TXA should be administered to all bleeding trauma patients, not just those with confirmed hyperfibrinolysis 1
• Protocols should consider administration of the first dose en route to the hospital 1
• TXA is distributed throughout all tissues with a plasma half-life of 120 minutes 1
• The cost-effectiveness of TXA in trauma has been demonstrated across various income settings 1
• No increased risk of thrombosis has been demonstrated in clinical trials 4

Potential Adverse Effects

While generally well-tolerated, clinicians should be aware of:

• Nausea and diarrhea (most common adverse events) 4
• Potential increased risk of venous thromboembolism (but not arterial thromboembolism) 5
• Possible increased risk of seizures at high doses 1

By following these evidence-based dosing recommendations, clinicians can optimize the mortality benefit of TXA in bleeding trauma patients while minimizing potential risks.