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Antifibrinolytic — Vascular / Surgical Haemostasis Pregnancy: Safe — used for PPH; crosses placenta minimally; WOMAN trial included pregnant women

Tranexamic Acid

Brand names: Cyklokapron, Femstrual (topical)

Adult dose

Dose: Surgical haemostasis: 10–15 mg/kg IV (1 g in most adults) before surgery + 1 g at 3 hours; Major haemorrhage (trauma): 1 g IV over 10 minutes, then 1 g over 8 hours (within 3 hours of injury)
Route: Intravenous (surgical/trauma) or oral (prophylaxis)
Frequency: Twice (surgical — pre-op + intraoperative); Once then infusion (trauma)
Max: 3 g/day (surgical); 2 g total (trauma CRASH-2 protocol)
CRASH-2 protocol: 1 g loading dose within 3 hours of injury (give even if uncertain — do NOT give after 3 hours, increases mortality). For vascular surgery: topical TXA applied to wound, IV peri-operative dosing, or oral post-operative. Antifibrinolytic — not a procoagulant; does not cause thrombosis at therapeutic doses in most patients.

Paediatric dose

Dose: 15 mg/kg IV mg/kg
Route: IV
Frequency: Up to 3 times daily
Max: 1.5 g per dose
BNFc: used in paediatric surgical haemostasis and haemophilia; CRASH-3 trial data emerging for paediatric TBI

Dose adjustments

Renal

CrCl 10–50: reduce dose; CrCl <10: use with caution — accumulates; risk of seizures at high plasma levels

Hepatic

No dose adjustment required

Paediatric weight-based calculator

BNFc: used in paediatric surgical haemostasis and haemophilia; CRASH-3 trial data emerging for paediatric TBI

Clinical pearls

  • CRASH-2 (2010): TXA within 3 hours reduces all-cause mortality in trauma by 9% — RR 0.91; after 3 hours: increased mortality (lysis of beneficial physiological clot?); time window is absolute
  • WOMAN trial (2017): TXA reduces death from PPH when given within 3 hours — same time-window principle
  • POISE-3 trial (2022): perioperative TXA reduces major bleeding in non-cardiac surgery with modest increase in arterial thrombosis — risk/benefit favours use in high-bleeding-risk surgery
  • Seizures are a dose-dependent toxicity — mechanism via glycine receptor antagonism in brain; highest risk in renal failure and cardiac surgery (high-dose protocols)
  • Topical TXA (soaked gauze or solution poured into wound) — effective haemostasis with minimal systemic absorption

Contraindications

  • Active thromboembolic disease
  • Subarachnoid haemorrhage (relative — may worsen vasospasm)
  • Haematuria of upper urinary tract origin (risk of ureteric clot obstruction)
  • History of seizures (high doses)

Side effects

  • Nausea and vomiting
  • Diarrhoea
  • Hypotension (if IV given too rapidly)
  • Seizures (at high plasma concentrations — especially in renal failure)
  • Thromboembolism (theoretical — limited clinical evidence at therapeutic doses)
  • Colour vision changes (long-term oral use)

Interactions

  • Factor IX complex/anti-inhibitor coagulant concentrate — increased thrombotic risk
  • Hormonal contraceptives — additive thrombotic risk theoretically

Monitoring

  • Renal function (dose adjustment)
  • Signs of VTE
  • Vision changes (long-term oral use)
  • Neurological status (seizure risk at high doses)

Reference: BNFc; BNF 90; CRASH-2 Trial 2010; WOMAN Trial 2017; POISE-3 Trial 2022; NICE NG24 (Major Trauma). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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