What is the recommended dosage of tranexamic acid (TXA) for treating heavy menstrual bleeding, trauma, and surgical procedures?

Tranexamic Acid Dosing Recommendations

For trauma, administer tranexamic acid 1 gram IV over 10 minutes immediately, followed by 1 gram infused over 8 hours; for heavy menstrual bleeding, use 3.9 grams daily (divided doses) for up to 5 days during menstruation; and for surgical procedures, give 10-15 mg/kg bolus followed by 1-5 mg/kg/hour infusion. 1, 2, 3

Trauma and Acute Hemorrhage

The critical window for tranexamic acid administration in trauma is within 3 hours of bleeding onset—beyond this timeframe, the drug may cause harm rather than benefit. 1

• Initial dose: 1 gram IV over 10 minutes, administered as soon as possible after bleeding begins 1
• Maintenance dose: 1 gram IV infused over 8 hours 2
• Timing is paramount: Benefit decreases by 10% for every 15-minute delay in administration 1
• Do not administer if more than 3 hours have elapsed since bleeding onset, as this increases risk of harm 1

Postpartum Hemorrhage (Specific Context)

• First dose: 1 gram IV over 10 minutes for bleeding >500 mL after vaginal delivery or >1000 mL after cesarean section 1
• Second dose: Additional 1 gram if bleeding continues after 30 minutes or restarts within 24 hours 1
• Administer early as part of standard treatment, not as rescue therapy when other measures fail 1

Surgical Procedures

• Loading dose: 10-15 mg/kg IV bolus 2
• Maintenance infusion: 1-5 mg/kg/hour 2
• The Horrow regimen (10 mg/kg followed by 1 mg/kg/hour) has been validated to achieve therapeutic plasma levels of 10 μg/mL needed to inhibit fibrinolysis 2
• Pediatric trauma dosing: 15 mg/kg loading dose followed by 2 mg/kg/hour infusion 2

Heavy Menstrual Bleeding

For idiopathic heavy menstrual bleeding, the evidence-based dose is 3.9 grams daily divided into multiple doses for up to 5 days starting on the first day of menstruation. 3, 4

• Standard regimen: 1.3 grams (two 650 mg tablets) three times daily for up to 5 days during menstruation 3
• Alternative dosing: 3-4.5 grams daily in divided doses for 4-5 days has been used in clinical trials 4, 5
• The 3.9 g/day dose met all three primary efficacy endpoints in randomized trials, while the 1.95 g/day dose was less effective 3
• Reduces menstrual blood loss by 26-60% compared to baseline 4

Special Populations with Heavy Menstrual Bleeding

• Von Willebrand disease: Higher doses of 3 grams daily in four divided doses for the first 5 days of menstruation may be required for severe cases 6
• Standard 1 gram daily dosing often fails in patients with bleeding disorders; escalation to 3 grams daily has proven safe and effective for 3-5 years of continuous use 6

Renal Impairment Dosing

Dose reduction is mandatory in renal impairment as tranexamic acid is renally excreted and accumulates in renal failure. 7, 2

• Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily 7
• Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily 7
• Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours OR 5 mg/kg every 24 hours 7
• These reductions apply to all indications, including both acute trauma and chronic menstrual bleeding management 7

Administration Guidelines

• Infusion rate: No faster than 1 mL/minute to avoid hypotension 7
• Compatible solutions: May be mixed with electrolyte solutions, carbohydrate solutions, amino acid solutions, and dextran solutions 7
• Heparin compatibility: Can be added to tranexamic acid injection 7
• Incompatibilities: Do NOT mix with blood products or penicillin-containing solutions 7
• Storage of diluted mixture: Up to 4 hours at room temperature 7

Critical Contraindications

Active thromboembolic disease is an absolute contraindication; do not use tranexamic acid in patients with current venous or arterial thrombosis. 7, 1

• Absolute contraindications: Subarachnoid hemorrhage (risk of cerebral edema and infarction), active intravascular clotting, hypersensitivity to tranexamic acid 7
• History of thrombosis or thromboembolism is considered a contraindication in the United States 1, 4
• Avoid concomitant use with pro-thrombotic agents including Factor IX concentrates, anti-inhibitor coagulant concentrates, and hormonal contraceptives 7

Common Pitfalls to Avoid

• Route confusion: Tranexamic acid injection is for IV use only—intrathecal administration has caused seizures and cardiac arrhythmias 7
• Delayed administration: Waiting for laboratory confirmation in trauma or postpartum hemorrhage reduces effectiveness; clinical diagnosis should suffice 1
• Inadequate dosing for menorrhagia: The 1.95 g/day dose is less effective than 3.9 g/day; use the higher dose for optimal results 3
• Missing the therapeutic window: Administration beyond 3 hours in acute bleeding may increase harm 1
• Withholding second dose: In postpartum hemorrhage, if bleeding continues or recurs within 24 hours, the second 1 gram dose is part of standard protocol, not optional 1