TXa
presentation - what the drug is sealed in, its concentration and how it might look
500mg in 5ml vials
INDICATIONS - reasons you should administer this drug
Trauma
Treatment of known or suspected severe traumatic internal or external haemorrhage as soon as clinically possible on arrival at the scene and within 3hrs of bleeding starting in adults and children who are considered to be at risk of significant haemorrhage. This may be demonstrated by one or more of:
Systolic blood pressure <90mmHG.
absent radial pulse or heart rate >110bpm believed to be due to bleeding in adults.
In children this may be demonstrated by changes in the normal physiological parameters for age.
Any patient where haemostatic gauze, arterial tourniquet(s), chest dressing(s) or pressure dressing(s) have been applied.
Patient who has suffered a traumatic cardiac arrest.
The above would include individuals who have recently given birth but have suffered subsequent trauma. Individuals who are pregnant and/or breastfeeding should have tranexamic acid administered in life-threatening haemorrhage.
Head Injury
Patients who have a known or suspected head injury where the following criteria is met:
The GCS is 12 or less.
The injury has occurred within the last 3 hours.
This includes individuals who are pregnant and those who have recently given birth (including those who are breastfeeding).
Post-partum Haemorrhage
Any of the following criteria:
Primary PPH: Blood loss of 500mls or more or any blood loss that results in clinical signs of hypovolaemic shock. Occurs within 24 hours of birth. Tranexamic acid should be administered within 3 hours of onset of excessive bleeding (500mls or more).
Secondary PPH: Excessive bleeding from the birth canal between 24 hours and 6 weeks post birth (if a maternity sanitary pad is soaked within 30 minutes). Individuals for whom uterotonic drugs (misoprostol) are contraindicated (rare).
Individuals who are breastfeeding should have tranexamic acid administered in life-threatening haemorrhage.
Excessive Vaginal Bleeding
Individuals with excessive bleeding following a termination of pregnancy or confirmed miscarriage i.e. filling a sanitary pad within 30 minutes or has lost 500ml or more of blood.
Individuals with unconfirmed miscarriage with life-threatening bleeding Life-threatening bleeding of other gynaecological origin.
CONTRAINDICATIONS - reasons you should not administer this drug
Known previous anaphylactic reaction to tranexamic acid or any component of the product.
Known or suspected GI haemorrhage (Current evidence does not support use).
Trauma / head injury:
Bleeding started more than 3 hours ago Obvious resolution of haemorrhage.
Confirmed miscarriage:
Where bleeding started more than 3 hours ago.
Primary PPH:
Where bleeding started more than 3 hours ago.
Note that a primary PPH occurs within 4 hours (but up to 24 hours) after delivery but actual bleeding should not have started more than 3 hours ago.
Secondary PPH:
Where excessive bleeding has started more than 3 hours ago.
cautions - reasons that if you administer this drug you must monitor for side effects more than usual
Severe hypertension may occur in patients on non-cardioselective beta-blockers (e.g. propranolol).
pharmacological action - what does it to the body and what does the body do to it?
FREC 3 and FREC 4:
Anti-fibrinolytic which reduces the breakdown of blood clot.
FREUC 5 and L4 AAP
Pharmacokinetics:
Absorption: Given IV/IO. Rapid onset within minutes; peak plasma concentration ~5–15 minutes after administration.
Distribution: Widely distributed in extracellular fluids; crosses the placenta and enters breast milk; minimal penetration of the blood–brain barrier unless meninges are inflamed.
Metabolism: Very little hepatic metabolism; TXA is largely not metabolised and remains unchanged in circulation.
Elimination: Primarily renal excretion as unchanged drug; ~90–95% eliminated in urine within 24 hours. Plasma half-life ~2–3 hours (longer in renal impairment).
Pharmacodynamics
Mechanism:
TXA is a synthetic lysine analogue that competitively inhibits plasminogen activation.
Blocks the binding of plasminogen to fibrin → prevents conversion to plasmin → reduces fibrin breakdown.
Effects:
Stabilises existing clots by preventing fibrinolysis.
Reduces bleeding in trauma, obstetric haemorrhage, and surgical contexts.
Supports microvascular clot integrity, improving haemostasis.
No direct pro-coagulant effect; it simply prevents premature clot breakdown.
Clinical notes:
Greatest benefit when given within 3 hours of traumatic haemorrhage (ideally within 1 hour).
Does not cause vasoconstriction, increased clot formation, or platelet activation.
Caution in patients with renal impairment due to reduced clearance..
side effects - unwanted secondary effects of this drug
Common (>1 in 100 but <1 in 10):
Nausea
Vomiting
Diarrhoea
Serious adverse effects (unknown rate of incidence):
Hypersensitivity reaction including anaphylaxis
Rapid injection may cause hypotension & loss of consciousness
Dizziness
Arterial or venous embolism at any site
Seizures
For a complete list of side-effects refer to the Summary of Product Characteristics on the electronic medicines compendium (emc) website.
dosage and administration - how much do we give and how do we give it?
Intravenous/intraosseous:
Administer SLOWLY over 10 minutes – can be given as 10 aliquots administered 1 minute apart Rapid injection may cause hypotension and loss of consciousness.
DO NOT administer through the same line as blood products or penicillin antibiotics, ideally use separate lines. Where not possible flush the cannula well between doses.
After administration flush with sodium chloride 0.9% following local policy for flush administration.
Intramuscular:
Give into a large muscle, in divided doses, with consideration of muscle mass, e.g. for an adult, 2 x 5 mL IM at separate sites (1g IM).
In Haematology patients the IV route is preferred as IM will cause minor bleeds / haematomas
Adults:
Trauma/Head Injury
Route: IM/IV/IO
Initial dose: 1g
Repeat dose: NA
Dose Interval: NA
Concentration: 100mg/1ml
Volume: 10ml
Max dose: 1g
Post Partum Haemorrhage (Pirmary and Secondary):
In PPH, a second dose can be administered if bleeding continues after 30 minutes of the first dose being administered. Any further doses are not permissible within 24 hours.
Route: IM/IV/IO
Initial dose: 1g
Repeat dose: 1mg
Dose Interval: 30 minutes
Concentration: 100mg/1ml
Volume: 10ml
Max dose: 2g
Excessive vaginal bleeding during confirmed miscarriage, termination of pregnancy or life-threatening bleeding during pregnancy:
Route: IM/IV/IO
Initial dose: 1g
Repeat dose: 1g
Dose Interval: 30 minutes
Concentration: 100mg/1ml
Volume: 10ml
Max dose: 2g
Excessive vaginal bleeding of unknown origin:
Route: IM/IV/IO
Initial dose: 1g
Repeat dose: NA
Dose Interval: NA
Concentration: 100mg/1ml
Volume: 10ml
Max dose: 1g
Minor trauma in haemophilia patients:
Route: IV
Initial dose: 1g
Repeat dose: NA
Dose Interval: NA
Concentration: 100mg/1ml
Volume: 10ml
Max dose: 1g
Children:
Please see JRCALC Page for Age guidelines.
Tip: Due to it’s low cost and high reward profile, K2 International recommends drawing up several doses at the same time into 2ml syringes (4 doses per syringe). This will allow you to give 0.5 ml accurately per does, but give you mulptile pre-draw doses so you are not drawing up drugs enroute to ED.
legislation and regulations - what legal class of drug is it, who can possess it and who can give it?
TXA is a Prescription-Only Medicine (POM) however TXA is commonly authorised for non-prescriber use in ambulance services via Patient Group Directives (PGD). Therefore:
As a POM, TXA would normally require a prescription from an authorised prescriber such as a medical doctor or Advanced Paramedic.
In UK pre-hospital practice, TXA is administered under Patient Group Directions (PGDs) which give give HCPs exemptions to possess and administer it.
bibliography
CRASH-2 trial collaborators (2010). Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. The Lancet, 376(9734): 23–32. 2.
CRASH-2 trial collaborators (2011). The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. The Lancet, 377(9771): 1096–101.e2.
Yeguiayan J-M, Rosencher N, Vivien B. (2011) Early administration of tranexamic acid in trauma patients. The Lancet, 378(9785): 27–8
Cap AP, Baer DG, Orman JA, Aden J, Ryan K, Blackbourne LH (2011). Tranexamic acid for trauma patients: a critical review of the literature. Journal of Trauma and Acute Care Surgery 2011, 71(1): S9–14: doi 10.1097/TA.0b013e31822114af.
NHS Evidence (2011). Tranexamic acid. Available from:
World Maternal Antifibrinolytic Trial (The WOMAN Trial) (2017). Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo controlled trial. The Lancet, 389(10084): 2105–2116. Available from: http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext
World Health Organization (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage. Available from: https://apps.who.int/iris/bitstream/handle/10665/75411/9789241548502_eng.pdf;jsessionid=FE21E3AB386D8541DD10B4973CA037B9?sequence=1
The CRASH-3 trial collaborators (2019). Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The Lancet, 394(10210): 1713–1723.
British National Formulary (2021) Tranexamic Acid. Available at:
National Institute for Health and Clinical Excellence (2023). Head Injury: Assessment and early management. London: NICE. Available from: https://www.nice.org.uk/guidance/ng232
Medusa NHS Injectable Medicines Guide (no date). Tranexamic acid intravenous – Adult. Version 9 published 27/11/23 and reviewed 17/5/23. Accessed 19/4/24.
Electronic Medicines Compendium (no date) Cyklokapron 100 mg/mL solution for injection/infusion - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk). Accessed 21/4/24.
Tranexamic Acid and breastfeeding (no date). Are they compatible? (e-lactancia.org). Accessed 21/4/24.
Tranexamic Acid - Drugs and Lactation Database (LactMed®) (no date) - NCBI Bookshelf (nih.gov). Accessed 21/4/24.
Resuscitation Council (UK) )(no date). Available at: www.resus.org.uk
Email correspondence from Dr Gary Benson, Director NI Haemophilia Comprehensive Care Centre and Thrombosis Unit, Consultant Haematologist/ Clinical Director Blood Sciences BHSCT