What is the recommended dosing for intravenous (IV) Tranexamic acid (TXA) injection?

Recommended Dosing for Intravenous Tranexamic Acid (TXA)

The standard recommended dosing for intravenous tranexamic acid (TXA) in trauma and significant bleeding is a loading dose of 1g administered over 10 minutes, followed by a maintenance dose of 1g infused over 8 hours. 1, 2

Primary Dosing Recommendations

• Trauma/Significant Bleeding:

  • 1g IV over 10 minutes, followed by 1g over 8 hours 1, 2
  • Must be administered within 3 hours of injury/bleeding onset 1, 2
  • Maximum benefit achieved when given within 1 hour 1

• Alternative Dosing Regimens:

  • 10-15 mg/kg followed by infusion of 1-5 mg/kg/h 2, 3
  • For specific procedures (e.g., tooth extraction in hemophilia): 10 mg/kg as a single dose immediately before procedure 4

Clinical Setting-Specific Dosing

Clinical Setting	Recommended Dose
Trauma	1g IV over 10 minutes, followed by 1g over 8 hours
Cardiac/Major Non-Cardiac Surgery	1g IV over 10 minutes, followed by 1g over 8 hours
Postpartum Hemorrhage	1g IV over 10 minutes, with a second 1g dose if bleeding continues after 30 minutes
Hemoptysis	1g IV every 8 hours, not exceeding 3g daily
[2]

Dosage Adjustments for Renal Impairment

TXA is primarily eliminated by the kidneys, requiring dose adjustment in 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
[2,4]

Critical Timing Considerations

• Early administration is crucial for efficacy:
  • ≤1 hour from injury: Significant reduction in death due to bleeding (RR 0.68) 1
  • 1-3 hours from injury: Moderate reduction in death due to bleeding (RR 0.79) 1

  • 3 hours from injury: May increase risk of death due to bleeding (RR 1.44) - DO NOT administer after 3 hours 1, 2

Administration Guidelines

• Infuse at a rate not exceeding 1 mL/minute (100 mg/minute) to avoid hypotension 4
• Can be mixed with most IV solutions (electrolytes, carbohydrates, amino acids, Dextran) 4
• Compatible with heparin 4
• Do NOT mix with:
  • Blood products
  • Solutions containing penicillin 4

Contraindications and Precautions

• Absolute contraindications:

  • Subarachnoid hemorrhage
  • Active intravascular clotting
  • Hypersensitivity to tranexamic acid 2, 4

• Use with caution in:

  • History of thromboembolism
  • Cardiac conditions
  • Massive hematuria (risk of ureteric obstruction)
  • Patients on oral contraceptives (increased thrombosis risk) 2, 4

Monitoring

• Monitor for potential adverse effects:
  • Common: nausea, vomiting, diarrhea, hypotension
  • Rare but serious: seizures (especially with high doses), thrombotic events 2, 4
• Consider monitoring fibrinolysis using thromboelastometric monitoring when available 2
• Consider discontinuing once bleeding is adequately controlled 2

Special Considerations

• TXA should not be routinely used in cancer-related DIC except when therapy-resistant bleeding dominates 2
• High-dose IV TXA is not recommended for gastrointestinal bleeding due to increased risk of thrombotic events without significant mortality benefit 2, 5, 6
• In cardiac surgery, maximum total dose should not exceed 100 mg/kg, especially in patients over 50 years of age, due to risk of neurotoxicity 7

Remember that TXA should be administered to all patients with significant bleeding, not just those with major hemorrhage, for maximum population benefit 1.