Should I add tranexamic acid (TXA) to my treatment regimen?

Should You Add Tranexamic Acid to Your Treatment Regimen?

Yes, you should add tranexamic acid (TXA) if your patient is actively bleeding or at risk of significant bleeding in trauma, post-partum hemorrhage, or certain surgical contexts—but only if administered within 3 hours of injury/bleeding onset, as effectiveness decreases by 10% every 15 minutes and may cause harm beyond this window. 1, 2

Clinical Context Determines TXA Use

Trauma and Active Hemorrhage

• Administer TXA immediately for trauma patients who are bleeding or at risk of significant bleeding, ideally en route to the hospital and definitely within 3 hours of injury 1
• The standard dosing regimen is 1 g IV over 10 minutes (loading dose), followed by 1 g IV infusion over 8 hours 1, 2
• Do not wait for viscoelastic assessment results before administering TXA 1
• Pre-hospital administration should be strongly considered to maximize benefit, as patients treated within 1 hour with shock index <0.9 had 65% lower 30-day mortality 1

Post-Partum Hemorrhage

• TXA is strongly recommended for all women with clinically diagnosed post-partum hemorrhage (>500 mL after vaginal birth or >1000 mL after cesarean section), regardless of whether bleeding is from trauma or uterine atony 1
• Give 1 g IV over 10 minutes as soon as post-partum hemorrhage is diagnosed 1
• Administer a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours 1
• This represents a broader indication than older 2012 guidelines, which restricted TXA to cases where uterotonics failed 1

Traumatic Brain Injury

• TXA reduces head injury-related death when given within 3 hours, particularly in mild to moderate TBI (not severe TBI) 1, 2
• Use the same dosing: 1 g IV over 10 minutes, then 1 g over 8 hours 1

Critical Timing Considerations

The 3-Hour Window

• Administration after 3 hours post-injury is suspected to be potentially harmful and may increase risk of death due to bleeding 1, 2
• Benefit decreases by 10% for every 15-minute delay in administration 1, 2
• Earlier treatment (≤1 hour) significantly reduces mortality 2

Absolute Contraindications

Do not administer TXA if:

• Active intravascular clotting is present 3
• Patient has subarachnoid hemorrhage (may cause cerebral edema and infarction) 3
• Known hypersensitivity to tranexamic acid 3
• More than 3 hours have elapsed since injury/bleeding onset 1

Route of Administration

• Intravenous administration is the only evidence-based and FDA-approved route 1, 4, 3
• Intrathecal administration is absolutely contraindicated and has caused seizures and cardiac arrhythmias 3
• Intramuscular dosing lacks clinical trial evidence and is not recommended by current guidelines 4
• Clearly label syringes with "IV ONLY" to prevent route errors 3

Dose Adjustments for Renal Impairment

Reduce dosing based on serum creatinine: 3

• Creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily
• Creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily
• Creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours

Safety Warnings and Monitoring

Seizure Risk

• TXA may cause focal or generalized seizures, particularly at high doses (>100 mg/kg total dose) 3
• Consider EEG monitoring for patients with seizure history or who show myoclonic movements 3
• Discontinue immediately if seizures occur 3

Thromboembolic Risk

• Avoid concomitant use with pro-thrombotic agents (Factor IX concentrates, hormonal contraceptives) 3
• However, meta-analyses in trauma and obstetric populations have not shown increased thrombotic events at recommended doses 1, 5

Other Adverse Effects

• Hypotension can occur with rapid IV injection—always infuse over 10 minutes 3
• Gastrointestinal symptoms (nausea, vomiting, diarrhea) may resolve with dose reduction 3
• Dizziness may impair driving ability 3

Common Pitfalls to Avoid

1. Delaying administration while obtaining laboratory results or imaging 1—give TXA immediately based on clinical assessment
2. Administering beyond the 3-hour window 1, 2—this may increase mortality
3. Using intrathecal or incorrect routes 3—serious adverse events including seizures have occurred
4. Failing to adjust dose in renal impairment 3—increases seizure risk
5. Mixing with penicillin-containing solutions 3—incompatible

Surgical Contexts

• TXA reduces perioperative blood loss by approximately 25% in orthopedic, cardiac, and other major surgeries without increasing thrombotic events 5, 6
• For elective surgery, a single 30 mg/kg dose may be as effective as continuous infusion regimens 7
• Maximum total dose should not exceed 100 mg/kg, especially in patients over 50 years undergoing cardiac surgery 5