What is the recommended dose of tranexamic acid (TXA)?

Tranexamic Acid Dosing Recommendations

The recommended dose of tranexamic acid (TXA) for trauma patients is 1g IV over 10 minutes, followed by 1g IV over 8 hours, to be administered within 3 hours of injury for optimal mortality benefit. 1

Standard Dosing Regimens by Clinical Scenario

Trauma

• Loading dose: 1g IV over 10 minutes
• Maintenance: 1g IV over 8 hours
• Critical timing: Must be given within 3 hours of injury (greatest benefit if given within 1 hour)
• Note: Benefit decreases by 10% for every 15-minute delay 1

Postpartum Hemorrhage

• Initial dose: 1g IV over 10 minutes
• Additional dose: 1g if bleeding continues after 30 minutes or restarts within 24 hours 1

Pediatric Trauma

• Loading dose: 15 mg/kg IV
• Maintenance: 2 mg/kg/hour infusion 2

Hemophilia (Tooth Extraction)

• Pre-procedure: 10 mg/kg IV immediately before extraction
• Post-procedure: 10 mg/kg IV 3-4 times daily for 2-8 days 1, 3

Administration Routes

TXA is primarily administered intravenously, but alternative routes may be considered in specific situations:

• IV administration: Preferred route for acute situations
• IM administration: May be considered in low-resource settings when IV access is challenging
  • For IM administration, 30 mg/kg appears to provide serum concentrations comparable to IV administration 4

Dosage Adjustments for Renal Impairment

Serum Creatinine	TXA IV Dosage
1.36-2.83 mg/dL	10 mg/kg twice daily
2.83-5.66 mg/dL	10 mg/kg daily
>5.66 mg/dL	10 mg/kg every 48 hours or 5 mg/kg every 24 hours

1, 3

Important Clinical Considerations

Timing of Administration

• TXA should be administered as early as possible, ideally within 1 hour of injury
• No mortality benefit has been demonstrated when TXA is given after 3 hours from injury 2, 1
• Consider protocols for pre-hospital administration to minimize delays 2

Monitoring

• Monitor for fibrinolysis if possible using thromboelastometric monitoring
• Stop antifibrinolytic therapy once bleeding has been adequately controlled 2

Therapeutic Target

• In vitro studies suggest that a plasma concentration of 10-15 mg/L is required to inhibit fibrinolysis
• Concentrations between 5-10 mg/L may be partially inhibitory 5

Contraindications and Precautions

• Absolute contraindications:

  • Subarachnoid hemorrhage
  • Active intravascular clotting
  • Hypersensitivity to TXA or its ingredients
  • Administration after 3 hours from injury/bleeding onset 1, 3

• Use with caution in patients with:

  • Massive hematuria (risk of ureteric obstruction)
  • Patients using oral contraceptives (increased thrombosis risk) 1

Common Side Effects

• Nausea, vomiting, diarrhea
• Allergic dermatitis
• Giddiness and hypotension 1

Key Points for Implementation

1. Administer TXA as early as possible within the 3-hour window
2. Use the appropriate dosing regimen based on clinical scenario
3. Adjust dosing in patients with renal impairment
4. Monitor for contraindications and potential adverse effects
5. Consider pre-hospital administration protocols to minimize delays

TXA is highly cost-effective across different income settings, making it a valuable option for bleeding management globally 1.