Recommended Dosage of Tranexamic Acid (TXA) for Various Clinical Scenarios
The recommended standard dose of tranexamic acid for trauma-related hemorrhage is 1 g loading dose administered intravenously over 10 minutes, followed by 1 g infusion over 8 hours, with administration as early as possible and within 3 hours of injury. 1, 2
Trauma and Hemorrhage
- TXA should be administered as soon as possible after injury or onset of bleeding, as effectiveness decreases by 10% for every 15-minute delay 1, 2
- Early administration (≤1 hour from injury) significantly reduces mortality due to bleeding 2
- Administration after 3 hours post-injury may increase risk of death due to bleeding 2
- Pre-hospital administration should be considered to ensure early treatment 2
Stroke and Traumatic Brain Injury
- For stroke with hemorrhage, the recommended dose is 1 g intravenously over 10 minutes, followed by 1 g over 8 hours 3
- TXA has shown benefit in reducing head injury-related death when administered within 3 hours, particularly in mild to moderate traumatic brain injury 3, 2
- Current guidelines do not specifically recommend TXA for ischemic stroke 3
Hemophilia and Dental Procedures
- For patients with hemophilia undergoing tooth extraction, the FDA-approved dose is 10 mg/kg actual body weight intravenously as a single dose immediately before extraction 4
- Following tooth extraction, TXA may be administered for 2 to 8 days at a dose of 10 mg/kg actual body weight 3 to 4 times daily, intravenously 4
- Infusion rate should not exceed 1 mL/minute to avoid hypotension 4
Dosage Adjustments for Renal Impairment
- For moderate to severe renal impairment, dose adjustments are necessary 4:
- Serum creatinine 1.36 to 2.83 mg/dL: 10 mg/kg twice daily
- Serum creatinine 2.83 to 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
Alternative Routes of Administration
- Intravenous administration remains the recommended and evidence-based route 1, 3
- Current clinical guidelines do not include specific recommendations for intramuscular dosing of TXA 1
- While intramuscular bioavailability is high (approximately 105%), more well-designed studies are needed before this route can be recommended as an alternative to IV 5
- Oral bioavailability is approximately 46% 5
Safety Considerations
- TXA is contraindicated in patients with subarachnoid hemorrhage, active intravascular clotting, or hypersensitivity to the drug 4
- Higher doses of TXA are associated with increased risk of seizures, particularly in cardiac surgery patients 3, 2
- Avoid concomitant use with pro-thrombotic medical products 4
- The risk of venous thromboembolic events may be higher with TXA treatment 6
- TXA injection is for intravenous use only - serious adverse reactions including seizures and cardiac arrhythmias have occurred with inadvertent intrathecal administration 4
Historical and Alternative Dosing Regimens
- European guidelines from 2007 suggested TXA dosages of 10 to 15 mg/kg followed by an infusion of 1 to 5 mg/kg per hour 7
- For elective surgery, particularly cardiac surgery with cardiopulmonary bypass, TXA has been used at doses of 10 mg/kg followed by infusion of 1 mg/kg/hour 8
- For gastrointestinal bleeding, a high-dose 24-hour regimen (1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) did not reduce death from gastrointestinal bleeding compared to placebo 6
Common Pitfalls
- Delaying administration beyond 3 hours significantly reduces effectiveness and may increase mortality 1, 3, 2
- Using TXA in patients with contraindications such as subarachnoid hemorrhage or active intravascular clotting 4
- Administering TXA too rapidly (faster than 1 mL/minute), which may cause hypotension 4
- Failing to adjust dosage in patients with renal impairment 4
- Using TXA in ischemic stroke patients who are candidates for thrombolytic therapy could theoretically counteract the beneficial effects of thrombolytics 3