Maximum Dose of Tranexamic Acid in Pediatric Patients
The maximum dose of tranexamic acid (TXA) in pediatric patients is 3-4 g per day, regardless of the indication. 1, 2, 3
Dosing Guidelines by Clinical Scenario
Trauma and Surgery
- For trauma and major surgical procedures, the recommended dose is 15 mg/kg loading dose followed by 2 mg/kg/hour infusion 1, 2, 4
- This dosing regimen has been widely adopted by pediatric trauma centers in the United States, with 68% using 15 mg/kg as the initial dose 4
- A follow-up infusion is utilized by 87% of programs, most commonly dosed at 2 mg/kg/hr for 8 hours 4
Menorrhagia in Adolescents
- For adolescents with menorrhagia, the recommended dose is 30-50 mg/kg/day divided into 2-3 doses 1, 2, 3
- For older adolescents (>12 years), dosing can start at 500 mg twice daily, gradually increasing up to 1000 mg 3-4 times daily as needed 3
- In all cases, the maximum daily dose should not exceed 3-4 g 1, 2, 3
Hereditary Angioedema Prophylaxis
- For hereditary angioedema prophylaxis, the maximum dose is 15-25 mg/kg two to three times daily, not exceeding 3 g/day 1, 2
Special Considerations
Timing of Administration
- TXA should be administered as early as possible in trauma cases, ideally within 3 hours of injury 1
- Delaying TXA administration reduces benefit significantly, and administration beyond 3 hours may potentially be harmful 1
Renal Impairment
- Dose adjustment is necessary for pediatric patients with renal impairment as TXA is primarily eliminated through the kidneys 2, 3
Contraindications
- Recent thrombosis, atrial fibrillation, or known thrombophilia are relative contraindications for TXA 2, 3
Pharmacokinetic Considerations
- Based on pharmacokinetic studies in infants and neonates undergoing cardiac surgery, some researchers have proposed a modified dosing regimen (the "10-10-4-4 rule"): 10 mg/kg TXA as a bolus, followed by 10 mg/kg/h infusion, then a 4 mg/kg bolus into the cardiopulmonary bypass prime and a reduced infusion of 4 mg/kg/h after the start of CPB 5
- This modified regimen aims to maintain therapeutic plasma concentrations above 20 μg/ml (the threshold for effective inhibition of fibrinolysis) while avoiding high peak concentrations that might increase seizure risk 5
Safety Profile
- TXA is generally well-tolerated in pediatric patients when used at appropriate doses 6
- No significant increase in thromboembolic events has been observed in pediatric patients receiving TXA compared to control groups 6, 7
- In a study of prehospital TXA administration in pediatric trauma patients, no adverse events were reported (upper limit of 95% CI for adverse events was 4.3%) 8
Clinical Application
- Weight-based dosing is preferred over body surface area-based dosing for ease of calculation 6
- Fixed adult doses should not be used in pediatric patients without weight-based calculation, as this can lead to under or overdosing 1
- For most indications, the maximum daily dose should not exceed 3-4 g, regardless of the child's weight 1, 2, 3