What is the recommended dose of Tranexamic acid (TXA) for heavy menstrual bleeding and surgical settings?

Tranexamic Acid Dosing

For heavy menstrual bleeding, administer tranexamic acid 1,300 mg orally three times daily (total 3.9 g/day) for the first 4-5 days of menstruation; for trauma and surgical hemorrhage, give 1 gram IV over 10 minutes followed by 1 gram infused over 8 hours, administered within 3 hours of bleeding onset. 1, 2

Heavy Menstrual Bleeding

The standard oral regimen is 1,300 mg three times daily (total 3.9 g/day) for 4-5 days starting from the first day of the menstrual cycle. 1, 3

• This dose has been validated in randomized controlled trials to reduce menstrual blood loss by 34-59% and is significantly more effective than placebo, NSAIDs, or oral progestins 4, 5
• The 3.9 g/day dose met all three primary efficacy endpoints in a large multicenter trial, whereas the lower 1.95 g/day dose did not 6
• Alternative dosing of 1 gram four times daily (total 4 g/day) is also acceptable and has demonstrated similar efficacy 7

Special Population: von Willebrand Disease

• For severe menorrhagia in von Willebrand disease patients, use 3 grams daily divided into four doses for the first 5 days of menstruation 8
• Adolescents with von Willebrand disease should receive weight-based dosing of 30-50 mg/kg/day divided into 2-3 doses (maximum 3-4 g/day) 3

Trauma and Acute Hemorrhage

Administer 1 gram IV over 10 minutes immediately upon diagnosis, followed by 1 gram IV infused over 8 hours. 1, 2

Critical Timing Considerations

• The drug must be given within 3 hours of bleeding onset—this is non-negotiable. 1, 2
• Effectiveness decreases by 10% for every 15-minute delay in administration 1, 2
• Administration beyond 3 hours may cause harm rather than benefit and should be avoided 1
• Do not wait for laboratory confirmation; clinical diagnosis suffices 1

Pediatric Trauma Dosing

• Loading dose: 15 mg/kg IV bolus 1
• Maintenance infusion: 2 mg/kg/hour 1

Postpartum Hemorrhage

Give 1 gram IV over 10 minutes for bleeding >500 mL after vaginal delivery or >1,000 mL after cesarean section. 9, 1

• Administer a second dose of 1 gram if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
• Must be given within 1-3 hours of bleeding onset to reduce maternal mortality 9
• The WOMAN trial demonstrated reduced bleeding-related mortality (RR 0.81) when administered within 3 hours, with a number needed to treat of 276 9

Surgical Procedures

Loading dose: 10-15 mg/kg IV bolus, followed by maintenance infusion of 1-5 mg/kg/hour. 9, 1

• The Horrow regimen (10 mg/kg followed by 1 mg/kg/hour) achieves therapeutic plasma levels of 10 μg/mL needed to inhibit fibrinolysis 9, 1
• Infuse no faster than 1 mL/minute to avoid hypotension 10
• Continue infusion until bleeding is adequately controlled 9

Renal Impairment Dosing Adjustments

Dose reduction is mandatory for all patients with renal dysfunction, as tranexamic acid is renally excreted. 3, 10

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

Contraindications and Safety

Absolute contraindications include active intravascular clotting, subarachnoid hemorrhage, and hypersensitivity to tranexamic acid. 10

• In the United States, history of thrombosis/thromboembolism or intrinsic thrombotic risk are also contraindications 1, 3, 4
• Avoid concomitant use with pro-thrombotic agents including Factor IX concentrates, anti-inhibitor coagulant concentrates, and hormonal contraceptives 1, 10
• Use with caution in patients taking oral contraceptives due to increased thrombotic risk 2
• Discontinue 5 days before high bleeding risk procedures 2

Common Pitfalls to Avoid

• Never administer intrathecally—this route causes seizures and cardiac arrhythmias; tranexamic acid is for IV use only 10
• Do not mix with penicillin-containing solutions or blood products 10
• Do not withhold the second dose in postpartum hemorrhage if bleeding continues or recurs within 24 hours 1
• Adverse events are primarily gastrointestinal (nausea, vomiting, diarrhea) occurring in approximately 12% of patients, similar to placebo rates 7
• No evidence exists of increased thrombotic events when used appropriately for heavy menstrual bleeding 4, 5