What are the uses of Tranexamic Acid (TXA)?

Tranexamic Acid (TXA) Uses

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

Primary Clinical Applications

Trauma Management

• Traumatic Bleeding: TXA should be given to trauma patients with active bleeding or at risk of significant bleeding 2
  • Most effective when administered within 1 hour of injury
  • Should be given within 3 hours of injury (efficacy decreases after this time)
  • Reduces mortality by approximately one-third when given within 3 hours 2
  • Pre-hospital administration should be considered for optimal timing 1

Surgical Applications

• Tooth Extraction in Hemophilia Patients: FDA-approved indication for short-term use (2-8 days) 3
  • Dosage: 10 mg/kg before extraction with replacement therapy
  • Post-extraction: 10 mg/kg 3-4 times daily for 2-8 days
• Cardiac and Non-Cardiac Surgery: Reduces perioperative blood loss 1, 4
• Orthopedic Surgery: Decreases blood loss and transfusion requirements 4

Obstetric Uses

• Postpartum Hemorrhage: 1 g IV over 10 minutes, with potential second dose if bleeding continues 1
  • Must be administered within 3 hours of birth
  • Efficacy decreases by 10% for every 15-minute delay
  • Applicable for all causes of postpartum hemorrhage (uterine atony, genital tract trauma, etc.)

Other Applications

• Traumatic Brain Injury: May reduce mortality in mild to moderate TBI when given early 2
• Heavy Menstrual Bleeding: Effective in reducing blood loss 5
• Hemoptysis: Maximum dose 1 g IV every 8 hours, not exceeding 3 g daily 1

Administration Guidelines

Dosing Protocol

• Standard Trauma Dosing: 1 g IV over 10 minutes, followed by 1 g over 8 hours 2, 1
• Timing: Administration within 3 hours of injury is critical 2
  • Early treatment (≤1 hour) shows greatest mortality benefit
  • Treatment between 1-3 hours still reduces mortality
  • Treatment after 3 hours may increase risk of death due to bleeding 2
• Dose Adjustment: Reduce dosage for patients with renal impairment 3

Important Considerations

• TXA administration should not await results from viscoelastic assessment 2
• TXA is highly cost-effective across different income countries 2, 1
• FOR INTRAVENOUS USE ONLY to avoid medication errors 3

Safety Profile

Adverse Effects

• Generally well-tolerated with common mild adverse effects including:
  • Nausea, vomiting, diarrhea
  • Allergic dermatitis
  • Giddiness and hypotension 1, 3

Contraindications

• Subarachnoid hemorrhage (risk of cerebral edema and infarction)
• Active intravascular clotting
• Severe hypersensitivity to TXA or ingredients 3

Precautions

• Risk of Thrombosis: Avoid concomitant use with Factor IX or prothrombotic medications 3
• Seizures: Higher doses associated with increased seizure risk 4, 6
• Visual Disturbances: Discontinue if visual symptoms occur 3
• Caution in Specific Conditions:
  • Massive hematuria (risk of ureteric obstruction)
  • Patients using oral contraceptives (increased thrombosis risk) 1

Clinical Decision-Making Algorithm

1. Assess for bleeding risk or active bleeding
2. Check contraindications: subarachnoid hemorrhage, active intravascular clotting, severe hypersensitivity
3. Determine time from injury/onset of bleeding:
   • If <3 hours: Administer TXA
   • If >3 hours: Consider risks vs. benefits (may be harmful in trauma)
4. Administer standard dose: 1 g IV over 10 minutes, followed by 1 g over 8 hours
5. Adjust dose if patient has renal impairment
6. Monitor for adverse effects: hypotension during infusion, seizures, visual disturbances

TXA has been shown to reduce mortality and morbidity across multiple clinical scenarios with a favorable safety profile when administered according to guidelines. The key to maximizing benefit is early administration, ideally within the first hour after injury or onset of bleeding.