Maximum Dose of Tranexamic Acid
The maximum dose of tranexamic acid (TXA) varies by indication, but generally should not exceed 4-4.5 g per day for adults when used for most indications. 1
Adult Dosing by Clinical Scenario
- For trauma and major bleeding: 1 g IV loading dose over 10 minutes, followed by 1 g infusion over 8 hours (total 2 g) 1
- For postpartum hemorrhage: 1 g IV (fixed dose) over 10 minutes, with a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours (maximum 2 g) 1
- For non-life-threatening major bleeding with NOACs: 1 g IV, repeated every 6 hours as needed 1
- For fibrinolysis management: 10-15 mg/kg followed by infusion of 1-5 mg/kg per hour 2, 1
- For menorrhagia: 30-50 mg/kg/day in 2-3 divided doses, with maximum daily dose of 3-4 g 1
- For hemophilia patients undergoing tooth extraction: 10 mg/kg IV immediately before extraction, followed by 10 mg/kg 3-4 times daily for 2-8 days 3
Pediatric Dosing
- For trauma and surgery: 15 mg/kg loading dose followed by 2 mg/kg/hour infusion 4, 1
- For menorrhagia in adolescents: 30-50 mg/kg/day in 2-3 divided doses, maximum 3-4 g daily 4, 1
- For hereditary angioedema prophylaxis: maximum dose of 15-25 mg/kg two to three times daily (not exceeding 3 g/day) 1
- General pediatric dosing: 10 ml/kg should increase hemoglobin by approximately 20 g/L 1
Dose Adjustments for Renal Impairment
- For serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily 3
- For serum creatinine 2.83-5.66 mg/dL: 10 mg/kg daily 3
- For serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 3
Important Considerations
- TXA should be administered as early as possible in trauma cases, ideally within 3 hours of injury 1
- For trauma patients, delaying TXA administration reduces benefit by approximately 10% for every 15 minutes 1, 5
- Continuous infusion is often needed to maintain therapeutic levels due to TXA's relatively short half-life of 120 minutes 6, 7
- In vitro studies suggest that a plasma concentration of 10 μg/ml is required to inhibit fibrinolysis 2, 7
- Avoid TXA in patients with active intravascular clotting, subarachnoid hemorrhage, or hypersensitivity to the drug 3
- Higher doses (30 mg/kg) may be required for intramuscular administration to achieve comparable serum concentrations to IV administration 8
Common Pitfalls
- Administering TXA beyond 3 hours after trauma may be potentially harmful rather than beneficial 1
- Failure to adjust dosing in patients with renal impairment can lead to drug accumulation 3
- Concomitant use with prothrombotic medications increases thrombosis risk 3
- Inadvertent intrathecal administration has caused serious adverse reactions including seizures and cardiac arrhythmias 3
- Using fixed adult doses in pediatric patients without weight-based calculation can lead to under or overdosing 1, 4