What is the recommended dosage and treatment plan for using tranexamic acid (TXA) for irregular bleeding?

Tranexamic Acid for Irregular Bleeding

Primary Recommendation

For irregular bleeding in the context of trauma or acute hemorrhage, administer tranexamic acid 1 g intravenously over 10 minutes, followed by 1 g infusion over 8 hours, starting as early as possible and within 3 hours of bleeding onset. 1, 2

Context-Specific Dosing

Trauma and Acute Hemorrhage

• Loading dose: 1 g IV over 10 minutes 1, 2
• Maintenance infusion: 1 g IV over 8 hours 1, 2
• Critical timing window: Must be administered within 3 hours of injury or bleeding onset 1, 2
• Pre-hospital administration: Should be considered to ensure early treatment, ideally at the site of injury 1

Heavy Menstrual Bleeding (Menorrhagia)

• Oral dosing: 3.9-4 g per day divided over 4-5 days, starting from the first day of menstruation 3
• Efficacy: Reduces menstrual blood loss by 26-60% compared to placebo 3
• Alternative to surgery: Can be used as first-line medical therapy for idiopathic heavy menstrual bleeding 3

Postpartum Hemorrhage

• Initial dose: 1 g for severe postpartum hemorrhage (>500 mL vaginal delivery, >1000 mL cesarean) 2
• Follow standard trauma dosing: 1 g loading dose followed by 1 g infusion over 8 hours 2

Critical Timing Considerations

The effectiveness of tranexamic acid decreases by 10% for every 15-minute delay in administration. 2, 4

• Within 1 hour of injury: Provides maximum benefit with 65% lower likelihood of 30-day mortality in trauma patients 1
• Between 1-3 hours: Still reduces risk of death due to bleeding (RR 0.79) 1
• After 3 hours: May actually increase risk of death due to bleeding (RR 1.44) and is NOT recommended 1, 2

Route of Administration

• Intravenous is the only evidence-based route with guideline support 2, 4
• Intramuscular administration: Not currently recommended by clinical guidelines due to lack of human clinical trial data comparing outcomes 2, 4
• Oral administration: Reserved specifically for menorrhagia, not for acute bleeding 3

Safety Profile and Contraindications

Absolute Contraindications

• Active thromboembolic disease (ongoing venous or arterial thrombosis) 3, 5
• History of thrombosis or thromboembolism (US FDA consideration) 3
• Allergy to tranexamic acid 6

Special Cautions

• Traumatic subarachnoid hemorrhage: Standard trauma TXA dosing does NOT apply when intracranial subarachnoid bleeding is present 7
• Renal insufficiency: Dose reduction required when creatinine >250 μmol/L 6
• Maximum total dose: Should not exceed 100 mg/kg to reduce seizure risk, particularly in patients over 50 years of age 2
• High-dose concerns: Doses above 100 mg/kg are associated with increased seizure risk, especially in cardiac surgery 2

Common Pitfalls to Avoid

Timing Errors

• Do not delay administration beyond 3 hours from injury or bleeding onset, as this significantly reduces effectiveness and may increase mortality 1, 2, 4
• Do not wait for laboratory confirmation of hyperfibrinolysis before administering TXA 1
• Do not limit use to only massive hemorrhage protocols—TXA should be given to all patients with significant bleeding 1

Population-Specific Errors

• Do not use standard trauma dosing in traumatic subarachnoid hemorrhage—guidelines recommend against routine use due to lack of functional benefit 7
• Do not use in ischemic stroke patients who are candidates for thrombolytic therapy, as TXA could counteract beneficial effects 2

Dosing Errors

• Do not exceed 100 mg/kg total dose to minimize seizure risk 2
• Do not use alternative routes (IM, oral) for acute trauma bleeding—IV is the only guideline-supported route 2, 4

Efficacy Evidence

• All-cause mortality reduction: 14.5% with TXA versus 16.0% with placebo (RR 0.91) in trauma patients 1
• Death due to bleeding reduction: 4.9% with TXA versus 5.7% with placebo (RR 0.85) 1
• No increased thrombotic risk: CRASH-2 trial showed lower rates of thrombosis, including myocardial infarction, with TXA use 1
• Menstrual blood loss reduction: 34-57.9% reduction versus placebo in menorrhagia 5

Adverse Effects

• Most common: Nausea and diarrhea, typically mild 5
• Serious events: Rare in clinical trials 8
• Seizures: Associated with high doses (>100 mg/kg), particularly in cardiac surgery patients 1, 2
• No demonstrated increased thrombotic risk in clinical trials 3, 5