Tranexamic Acid Infusion Dosing
For trauma-related hemorrhage, administer tranexamic acid as a 1 g loading dose intravenously over 10 minutes, followed by a 1 g infusion over 8 hours, initiated as soon as possible and within 3 hours of injury. 1, 2
Standard Dosing Regimen
The current evidence-based dosing for bleeding trauma patients is:
This regimen is supported by the landmark CRASH-2 trial involving over 20,000 trauma patients and represents the most robust evidence available. 3
Critical Timing Considerations
Time to administration is paramount for effectiveness:
- Optimal window: Within 3 hours of injury 1, 2
- Effectiveness decreases by 10% for every 15-minute delay 1, 2
- Early administration (≤1 hour) significantly reduces mortality from bleeding 2
- Administration after 3 hours may increase risk of death due to bleeding 1, 2
Pre-hospital administration should be strongly considered to ensure treatment within the therapeutic window. 2
Alternative Dosing Regimens
Historical Weight-Based Dosing
Older European guidelines suggested 10-15 mg/kg loading dose followed by 1-5 mg/kg/hour infusion. 4, 2 However, the fixed-dose regimen (1 g + 1 g) has become the standard based on superior trial evidence.
Single Bolus vs. Bolus-Plus-Infusion
Recent comparative data shows that clinical outcomes are equivalent between:
- 1 g bolus only
- 1 g bolus + 1 g infusion over 8 hours
- 2 g bolus 5
Single bolus administration may be preferable to bolus-plus-infusion for practical reasons, though the standard remains the CRASH-2 protocol. 5
Administration Details
Infusion rate: No more than 1 mL/minute to avoid hypotension 6
Route: Intravenous administration only—never intrathecal, as inadvertent neuraxial administration can cause seizures and cardiac arrhythmias 6
Dose Adjustments for Renal Impairment
For patients with renal dysfunction, reduce dosing as follows: 6
- Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily
- Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily
- Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours OR 5 mg/kg every 24 hours
Special Clinical Contexts
Traumatic Brain Injury
The same dosing regimen (1 g over 10 minutes, then 1 g over 8 hours) applies, with benefit demonstrated when given within 3 hours, particularly for mild-to-moderate TBI. 1, 2
Stroke with Hemorrhage
The recommended dose mirrors trauma dosing: 1 g IV over 10 minutes followed by 1 g over 8 hours. 1, 2 Note: TXA is not recommended for ischemic stroke and may counteract thrombolytics. 1, 2
Dental Surgery in Hemophilia Patients
FDA-approved dosing differs: 10 mg/kg as a single dose immediately before extraction, then 10 mg/kg 3-4 times daily for 2-8 days post-extraction. 6
Safety Considerations and Contraindications
Absolute contraindications: 6
- Active intravascular clotting
- Subarachnoid hemorrhage (risk of cerebral edema/infarction)
- Hypersensitivity to tranexamic acid
Important adverse effects:
- Seizures: Higher doses (>100 mg/kg total) associated with increased seizure risk, particularly in cardiac surgery patients 1, 2
- Venous thromboembolism: Increased risk compared to placebo (0.8% vs 0.4%) 7
- Hypotension: If infused too rapidly 6
Avoid concomitant use with prothrombotic agents (Factor IX concentrates, hormonal contraceptives) due to additive thrombotic risk. 6
Common Pitfalls to Avoid
- Delaying administration beyond 3 hours—this is the most critical error, as effectiveness drops precipitously and mortality risk may increase 1, 2
- Using in ischemic stroke patients who are thrombolytic candidates 1
- Rapid infusion—always infuse loading dose over 10 minutes to prevent hypotension 6
- Mixing with blood products or penicillin-containing solutions 6
- Intrathecal administration—verify IV route to prevent catastrophic neurologic complications 6