What are the indications for Tranexamic Acid (TXA)?

Tranexamic Acid (TXA) Indications

Tranexamic acid is indicated for trauma-related hemorrhage, postpartum hemorrhage, surgical bleeding prophylaxis, and hemophilia-related dental procedures, with administration required within 3 hours of bleeding onset for maximum efficacy.

FDA-Approved Indication

• TXA is FDA-approved for patients with hemophilia undergoing tooth extraction to reduce hemorrhage and decrease replacement therapy requirements for 2-8 days 1

Major Hemorrhage Indications

Trauma-Related Bleeding

• Administer TXA to all trauma patients who are bleeding or at risk of significant hemorrhage, with treatment initiated as early as possible and ideally within 3 hours of injury 2
• Early administration (≤1 hour) reduces bleeding death by 32%, while treatment between 1-3 hours provides 21% reduction in mortality 2
• Standard dosing: 1g IV loading dose over 10 minutes, followed by 1g infusion over 8 hours 2, 1
• Administration after 3 hours may paradoxically increase bleeding death risk and should be avoided 3, 2

Postpartum Hemorrhage

• WHO strongly recommends TXA for all clinically diagnosed postpartum hemorrhage within 3 hours of birth, regardless of whether bleeding is due to genital tract trauma or uterine atony 3, 2
• This represents a broader indication than previous recommendations that limited use to cases where uterotonics failed 3
• Dosing: 1g IV over 10 minutes, with a second 1g dose if bleeding continues after 30 minutes or recurs within 24 hours 2
• Efficacy decreases 10% for every 15-minute delay in administration 3, 2

Surgical Prophylaxis

Orthopedic Surgery

• TXA should be administered to all patients undergoing femur fracture surgery to reduce blood loss and transfusion requirements 2
• Administer 1g IV at the start of surgery, prior to incision 2

Gynecologic Surgery

• Administer 1g IV bolus over 10 minutes at the start of benign gynecologic surgery to reduce blood loss, transfusion requirements, and reoperations due to hemorrhage 2

Plastic and Major Surgery

• For procedures expected to exceed 2-3 hours, use standard trauma dosing: 1g loading dose followed by 1g maintenance infusion over 8 hours 2
• TXA has proven efficacy in cardiac surgery, major non-cardiac surgery, orthopedic arthroplasty, and vascular procedures 2

Critical Timing Algorithm

1. Identify bleeding or high-risk bleeding scenario
2. Calculate time from bleeding onset or injury
3. If ≤3 hours: Administer TXA immediately 3, 2
4. If >3 hours: Do NOT administer TXA due to potential harm 3, 2
5. For surgical prophylaxis: Administer before incision 2

Absolute Contraindications

• Active intravascular clotting or disseminated intravascular coagulation 2, 1
• Subarachnoid hemorrhage (may cause cerebral edema and infarction) 1
• Severe hypersensitivity to TXA 2, 1

High-Risk Situations Requiring Extreme Caution

• Post-stroke patients (thrombotic risk) 2, 4
• Massive hematuria (risk of ureteric obstruction) 2, 4
• Patients on oral contraceptive pills (increased thrombotic risk) 2
• Renal impairment requires dose adjustment as TXA is renally excreted 2, 1

Renal Dose Adjustments

• Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily 1
• Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily 1
• Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 1

Safety Profile

• No increased risk of arterial or venous thrombotic events demonstrated in over 8,000 patients receiving TXA 2
• Meta-analysis of 125,550 participants confirms no increased thromboembolic risk when used appropriately 2
• Higher doses are associated with increased seizure risk, particularly in cardiac surgery 2

Key Clinical Pitfalls to Avoid

• Do not delay administration waiting for laboratory results—early treatment is critical 2
• Do not administer after the 3-hour window from bleeding onset 3, 2
• Do not use topical TXA as a substitute for IV administration when systemic hemostatic support is needed 2
• Infuse no faster than 1 mL/minute to avoid hypotension 1
• Do not mix with penicillin-containing solutions or blood products 1