Tranexamic Acid (TXA)

• Core Use: Major trauma hemorrhage (CRASH-2 protocol), postpartum hemorrhage (WOMAN trial), and selected perioperative bleeding; synthetic lysine analogue that inhibits fibrinolysis
• Standard Adult Trauma Dose: 1 g IV over 10 minutes, then 1 g IV over 8 hours (many EMS systems give single 1 g bolus)
• Timing Critical: Maximum benefit when given within 1 hour of bleeding onset; benefit diminishes and potential harm increases when given >3 hours after trauma or childbirth
• Key Danger: Renally cleared; accumulation increases risk of seizures and thrombotic events at high/repeated doses, especially in renal impairment
• Special Note: NOT a substitute for blood products, source control, or balanced resuscitation—it's an adjunct that preserves existing clots by preventing fibrinolysis

• Generic Name: Tranexamic acid
• Brand Names: Cyklokapron, Lysteda (PO), various generics

Antifibrinolytic; synthetic lysine analogue; plasminogen activation inhibitor

Mechanism of Action:

• Tranexamic acid is a synthetic analogue of lysine that competitively inhibits the activation of plasminogen to plasmin by blocking lysine-binding sites on plasminogen and plasmin
• By inhibiting plasmin formation and activity, TXA stabilizes fibrin clots and reduces fibrinolysis, decreasing ongoing bleeding without directly affecting coagulation factor generation
• Does not promote new clot formation but preserves existing clots; however, by tipping the balance away from fibrinolysis, it can theoretically increase risk of thrombosis in patients with strong prothrombotic tendencies

Pharmacokinetics:

• Onset: Antifibrinolytic effect begins within minutes of IV administration
• Bioavailability (PO): ~30–50%; peak plasma levels in 2–3 hours with oral dosing
• Distribution: Volume of distribution ~9–12 L; crosses placenta and appears in breast milk at low levels
• Metabolism: Minimal; TXA is largely unchanged in circulation
• Elimination: Primarily renal excretion; half-life ~2–3 hours in normal renal function, prolonged in renal impairment

Available Forms:

• IV solution: commonly 100 mg/mL (e.g., 1 g in 10 mL vials); may be further diluted in 0.9% NaCl or D5W for infusion
• Oral tablets: typically 650 mg (Lysteda), 500 mg or 1 g tablets in some regions
• Topical/nebulized (off-label): IV formulation applied to gauze or diluted in saline for epistaxis or hemoptysis

Dosing – Tranexamic Acid (Adult; always follow local protocol):

Contraindications:

• Active intravascular clotting (e.g., acute DVT, PE, or active arterial thrombosis) unless benefits clearly outweigh risks
• History of TXA hypersensitivity or anaphylaxis
• Subarachnoid hemorrhage (risk of cerebral ischemia in older data)

Major Precautions:

• History of thromboembolic disease (DVT, PE, MI, stroke): use only when strong indication and in consultation with senior/hematology when possible
• Renal impairment: reduced clearance increases TXA levels; lower doses or extended intervals are required
• High-dose IV regimens have been associated with increased seizure risk; avoid unnecessarily high doses
• Hematuria from upper urinary tract (e.g., renal bleeding): risk of obstructive clots; use with caution or avoid

Common:

• Nausea, vomiting, diarrhea
• Dizziness, fatigue
• Nasal irritation or cough with nebulized/topical use

Serious:

• Venous thromboembolism (DVT, PE), arterial thrombosis (MI, stroke) – low absolute risk in most large trauma/PPH trials but possible in high-risk patients
• Seizures, particularly with high total doses, rapid IV administration, or in cardiac surgery settings
• Hypotension with rapid IV push (especially if given undiluted); recommended to infuse over 10 minutes
• Anaphylaxis or severe hypersensitivity reactions (rare)

Renal Impairment:

• Reduced clearance; dose reduction required in CrCl <30 mL/min
• Higher risk of accumulation leading to seizures and thrombotic events

Pregnancy & Lactation:

• Used in postpartum hemorrhage within 3 hours of delivery (WOMAN trial)
• Crosses placenta and appears in breast milk at low levels; considered acceptable when benefits outweigh risks

Elderly:

• May have reduced renal function; consider dose adjustments
• Monitor closely for thrombotic events

• Clinical control of bleeding (vital signs, visible bleeding, transfusion requirements)
• Hemoglobin/hematocrit and coagulation labs as part of broader hemorrhage management
• Signs and symptoms of thromboembolism (leg swelling, chest pain, hypoxia, neurologic deficits), especially in patients with pre-existing risk factors
• Renal function (serum creatinine, urine output), particularly with repeated or high-dose regimens
• Neurologic status for new-onset seizures or focal deficits after TXA exposure

• Suspected or confirmed significant traumatic hemorrhage in adults (and pediatrics per local protocol), particularly in patients with systolic hypotension, tachycardia, or signs of ongoing bleeding, when presentation is within 3 hours of injury
• Postpartum hemorrhage (PPH) due to uterine atony, trauma, or other obstetric causes, administered as soon as PPH is diagnosed and within 3 hours of birth
• Perioperative bleeding reduction in high-risk surgeries (e.g., orthopedic, cardiac, liver transplantation, major spine surgery) under anesthesia/surgical protocols
• Selected mucosal bleeding: epistaxis (topical TXA on packing) and hemoptysis (nebulized or endobronchial TXA) as adjunctive therapy in some institutions

• 1. CRASH-2 trial collaborators. (2010). The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomized controlled trial. The Lancet, 377(9771), 1096–1101.
• 2. WOMAN Trial Collaborators. (2017). Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): An international, randomized, double-blind, placebo-controlled trial. The Lancet, 389(10084), 2105–2116.
• 3. HALT-IT Trial Collaborators. (2020). Effects of a high-dose 24-hour infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT). The Lancet, 395(10241), 1927–1936.
• 4. Lexicomp. (2025). Tranexamic acid: Drug information. Wolters Kluwer.
• 5. EMCrit Project. (2023). Antifibrinolytics & TXA in critical care. https://emcrit.org/