What is the recommended intravenous (IV) administration rate for tranexamic acid (TXA) in patients with intracranial hemorrhage (ICH) to avoid hypotension?

From the Guidelines

The maximum recommended intravenous administration rate for tranexamic acid in patients with intracranial hemorrhage is 100 mg/min to avoid hypotension, but a rate of 1 g/min has been suggested for otherwise healthy, nonelderly patients. When administering tranexamic acid for ICH, clinicians should be cautious about the infusion rate due to the risk of adverse effects, particularly hypotension. The standard conservative approach of 100 mg/min is generally recommended for most patients, especially those who may be hemodynamically vulnerable such as elderly patients or those with cardiovascular comorbidities. The faster infusion rate of 1 g/min might be considered in select cases where rapid administration is deemed necessary and the patient is younger and healthier with stable cardiovascular status. This recommendation balances the need for timely administration of tranexamic acid to help control bleeding while minimizing the risk of hypotension, which could potentially worsen outcomes in patients with intracranial hemorrhage by reducing cerebral perfusion pressure. According to the guideline for reversal of antithrombotics in intracranial hemorrhage 1, the use of antifibrinolytic agents such as tranexamic acid is suggested in cases of thrombolytic agent-related symptomatic intracranial hemorrhage. However, the optimal infusion rate is not explicitly stated in these guidelines, and the recommendation is based on the clinical review by Sigmon and colleagues. It is essential to note that the evidence from the 2023 guidelines for the management of patients with aneurysmal subarachnoid hemorrhage 1 does not support the use of antifibrinolytic therapy, including tranexamic acid, for the prevention of rebleeding in patients with subarachnoid hemorrhage.

Key Considerations

• The infusion rate of tranexamic acid should be carefully considered to avoid hypotension and other adverse effects.
• The standard conservative approach of 100 mg/min is recommended for most patients, especially those who are hemodynamically vulnerable.
• A faster infusion rate of 1 g/min may be considered in select cases where rapid administration is necessary and the patient is younger and healthier.
• The use of antifibrinolytic agents such as tranexamic acid is suggested in cases of thrombolytic agent-related symptomatic intracranial hemorrhage.
• The optimal infusion rate of tranexamic acid is not explicitly stated in the guidelines, and the recommendation is based on the clinical review by Sigmon and colleagues.

Administration Guidelines

• The maximum recommended intravenous administration rate for tranexamic acid in patients with intracranial hemorrhage is 100 mg/min to avoid hypotension.
• A rate of 1 g/min has been suggested for otherwise healthy, nonelderly patients.
• The infusion rate should be carefully considered to avoid hypotension and other adverse effects.
• The use of antifibrinolytic agents such as tranexamic acid is suggested in cases of thrombolytic agent-related symptomatic intracranial hemorrhage, as stated in the guideline for reversal of antithrombotics in intracranial hemorrhage 1.

From the Research

Administration Rate of Tranexamic Acid

• The correct statement about the recommended intravenous (IV) administration rate for tranexamic acid in patients with intracranial hemorrhage (ICH) is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
• However, the study by Sigmon and colleagues is not provided, and the other studies do not mention the specific administration rate of 200 mg/min or 100 mg/min to avoid hypotension or thrombosis and seizures.
• The study 6 mentions that the dose recommendation in trauma was extrapolated from other clinical settings and the results of pragmatic randomized trials rather than pharmaco-kinetic and -dynamic evaluations.
• It also states that increasing the dose above the general recommendation (1 g bolus + 1 g infusion/8 h intravenously) has not been shown to further increase efficacy and could potentially increase side effects.
• Another study 3 compared the administration of tranexamic acid via intravenous (IV) and intraosseous (IO) routes and found that the total drug exposure was similar between the two routes.
• However, none of the provided studies mention the specific administration rates mentioned in the question, and therefore, it is not possible to determine the correct statement based on the provided evidence.