What are the indications and dosing guidelines for tranexamic acid (TXA) in clinical practice?

Tranexamic Acid (TXA): Indications and Dosing Guidelines

Tranexamic acid should be administered to trauma patients who are bleeding or at risk of significant bleeding as soon as possible, preferably within 3 hours of injury, at a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours. 1

Trauma-Related Bleeding

Indications

• Trauma patients with active bleeding or at risk of significant hemorrhage
• Most effective when administered within 1 hour of injury, with decreasing efficacy up to 3 hours 1, 2
• Should not be administered beyond 3 hours after injury as it may increase mortality 2

Dosing

• Loading dose: 1 g IV infused over 10 minutes
• Maintenance dose: 1 g IV infused over 8 hours
• Administration should not await viscoelastic assessment results 1

Postpartum Hemorrhage

Indications

• Clinically diagnosed postpartum hemorrhage, defined as:
  • Blood loss >500 mL after vaginal birth
  • Blood loss >1000 mL after cesarean section
  • Any blood loss sufficient to compromise hemodynamic stability 1, 2

Dosing

• 1 g IV over 10 minutes
• Second dose of 1 g if bleeding continues after 30 minutes or restarts within 24 hours 1
• Must be administered within 3 hours of birth 1, 3
• Efficacy decreases by 10% for every 15-minute delay 1

Surgical Settings

Indications

• Cardiac and major non-cardiac surgeries to reduce perioperative blood loss 2, 4
• Orthopedic procedures, particularly arthroplasty 4
• Oral surgery in patients with hemophilia 5, 6

Dosing

• Hemophilia patients undergoing dental extraction: 10 mg/kg IV immediately before extraction, followed by 10 mg/kg 3-4 times daily for 2-8 days 5
• Cardiac surgery: Maximum total dose of 100 mg/kg, especially in patients over 50 years due to potential neurotoxicity 4
• General surgery: 10-15 mg/kg IV (or 1 g) preoperatively 4

Other Indications

• Upper gastrointestinal bleeding: Associated with 40% reduction in mortality 6
• Menorrhagia: Reduces menstrual blood loss by 34-58% 6
• Hemoptysis: Maximum dose of 1 g IV every 8 hours, not exceeding 3 g daily 2

Dosage Adjustment for Renal Impairment

• Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily
• Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg daily
• Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 5

Contraindications and Precautions

• Subarachnoid hemorrhage (risk of cerebral edema and infarction) 5
• Active intravascular clotting 5
• Severe hypersensitivity to tranexamic acid 5
• Use with caution in patients with:
  • History of thromboembolic disease
  • Massive hematuria (risk of ureteric obstruction)
  • Patients using oral contraceptives (increased thrombosis risk) 2

Administration Pearls

• Infuse no more than 1 mL/minute to avoid hypotension 5
• May be mixed with most infusion solutions (electrolytes, carbohydrates, amino acids)
• Can be mixed with heparin but should NOT be mixed with blood or penicillin 5
• For IV use only - incorrect route administration may cause serious adverse effects 5

Safety Profile

• Generally well-tolerated with no increased risk of thromboembolic complications in most settings 2, 4
• Most common adverse effects: nausea, vomiting, diarrhea, allergic dermatitis, giddiness, hypotension 5
• Higher doses associated with increased risk of seizures, particularly in cardiac surgery patients 2, 4
• Increased risk of venous thrombosis observed in patients with gastrointestinal bleeding 7

TXA is a cost-effective intervention across low, middle, and high-income countries, making it a valuable treatment option in various clinical settings 2, 4. Early administration is critical for maximizing efficacy, particularly in trauma and postpartum hemorrhage 7, 3.