What is the administration protocol for Tranexamic Acid (TXA)?

From the Guidelines

Tranexamic acid should be administered to trauma patients who are bleeding or at risk of significant bleeding as soon as possible, with a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours, and ideally within 3 hours after injury. This recommendation is based on the most recent and highest quality study, which suggests that early administration of tranexamic acid can significantly reduce the risk of death due to bleeding in trauma patients 1. The European guideline on management of major bleeding and coagulopathy following trauma recommends the use of tranexamic acid in this context, with a Grade 1A recommendation for its administration as soon as possible, and within 3 hours after injury 1.

Some key points to consider when administering tranexamic acid include:

• The dose and administration schedule, which typically consists of a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 hours 1
• The importance of administering tranexamic acid as soon as possible, and ideally within 3 hours after injury, to maximize its efficacy in reducing the risk of death due to bleeding 1
• The potential side effects of tranexamic acid, which may include nausea, vomiting, and hypotension with rapid IV administration, although these are generally considered to be mild and self-limiting 1
• The need for renal dose adjustment in patients with kidney impairment, typically reducing the dose by 25-50% when creatinine clearance is below 50 ml/min, although this is not explicitly stated in the most recent guideline 1

It is also worth noting that the use of tranexamic acid has been shown to be cost-effective in trauma patients, with estimated incremental costs per life year gained of $48, $66, and $64 in Tanzania, India, and the UK, respectively 1. Overall, the evidence suggests that tranexamic acid is a safe and effective treatment for trauma patients who are bleeding or at risk of significant bleeding, and that it should be administered as soon as possible, and ideally within 3 hours after injury.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

2.1 Recommended Dosage The recommended dose of Tranexamic acid is 10 mg/kg actual body weight intravenously administered as a single dose, immediately before tooth extractions. Infuse no more than 1 mL/minute to avoid hypotension [see Warnings and Precautions (5. 1)]. Following tooth extraction, Tranexamic acid may be administered for 2 to 8 days at a dose of 10 mg/kg actual body weight 3 to 4 times daily, intravenously.

The administration of tranexamic acid is intravenous. The recommended dose is 10 mg/kg actual body weight as a single dose before tooth extractions, and 10 mg/kg actual body weight 3 to 4 times daily for 2 to 8 days after tooth extraction. The infusion rate should not exceed 1 mL/minute to avoid hypotension 2.

• Key administration considerations:
  • Intravenous administration only
  • Dose reduction for patients with renal impairment
  • Avoid concomitant use with prothrombotic medical products
  • Infuse no more than 1 mL/minute to avoid hypotension 2 2

From the Research

Tranexamic Acid Administration

• Tranexamic acid can reduce bleeding in patients undergoing elective surgery and has been shown to safely reduce the risk of death in bleeding trauma patients 3.
• The effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage have been assessed in the CRASH-2 randomised controlled trial 3.
• Early administration of tranexamic acid is crucial, as it has been shown to significantly reduce the risk of death due to bleeding when given within 1 hour of injury 4.
• The importance of early treatment with tranexamic acid in bleeding trauma patients has been highlighted, with treatment given after 3 hours seeming to increase the risk of death due to bleeding 4.

Indications and Controversies

• Tranexamic acid is used for the treatment or prevention of bleeding in various indications, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding 5.
• Despite its effectiveness, hesitancy in using tranexamic acid persists in many clinical settings, with controversies surrounding its use, such as the risk of thrombosis and prescription with combined hormonal contraceptives 5.
• The safety profile of tranexamic acid remains in question due to a potential increased risk of venous thromboembolism, although topical application may reduce systemic absorption and mitigate unwanted side-effects 6.

Efficacy and Safety

• Topical tranexamic acid has been shown to be effective in reducing blood loss and transfusion requirements, with no significant difference in thromboembolic risks compared to placebo or intravenous administration 6.
• The efficacy and safety of tranexamic acid have been estimated to potentially prevent many premature deaths every year, with the largest numbers of deaths averted in low and middle-income countries 7.
• The use of tranexamic acid in the treatment of traumatic bleeding has the potential to prevent many premature deaths every year, with early administration being crucial for its effectiveness 3, 4, 7.