Tranexamic Acid: Evidence and Clinical Applications
Tranexamic Acid! It seems everywhere we look there are people touting TXA as the next miracle drug. This post introduces the clinical applications of TXA and the evidence supporting its use.
- Trauma: CRASH-2 and MATTERS studies found significant mortality benefit when given within the first three hours (ideally within the first hour). Mortality increased when given after the three hour mark. CRASH-2 suggests administering to those patients with massive trauma and SBP <110.
- Hemoptysis: Small case series demonstrate reduction in bleeding time for patients with non-massive hemoptysis, though this has not been confirmed by any large, randomized trials
- Pediatric Trauma: No studies yet, but it is presumed that the pro-thrombotic risks would be diminished in children. Discuss with your consultant.
- Intracranial Hemorrhage: No dedicated studies but trends within CRASH-2 suggest benefit. Discuss with your consultant. The CRASH-3 trial will explore this further.
- GI Bleeding: A meta-analysis showed a mortality benefit in those with an UGIB. When studies using PPI/endoscopy were excluded, there was no benefit. Consider if patient rapidly exsanguinating. The HALT-IT RCT is pending and should provide further direction.
- Post-Partum Hemorrhage: 2015 Cochrane review concludes that TXA “decreases postpartum blood loss and prevents PPH and blood transfusion following vaginal birth and CS in women at low risk of PPH”. The World Maternal Antifibrinolytic Trial (WOMAN) is in process and could provide definitive evidence for TXAs use. Currently the WHO recommends its consideration should oxytocin or other uterotonics fail.
- Menorrhagia: Approved for use in menorrhagia by the FDA in 2009. Usually given as an oral formulation. Often given to those with contraindications to hormonal therapy.
- Traumatic Hyphema: A 2013 Cochrane review concluded that TXA had a significant reduction in the rate of secondary hemorrhage. Possible increased time to resolution of hyphema. Discuss with your consultant.
- Epistaxis: There is one RCT that showed a huge benefit of TXA but many are critical of the study’s design. Application is via TXA soaked merocel tampons with the caveat that nasal absorption is unknown and may have systemic effects.
- SAH: 2003 Cochrane review showed decreased risk of rebleeding. Discuss with your consultant.
- Generally systemic dosing is 1g given IV over 10 minutes.
- In general trauma, CRASH-2 suggests a second 1g given over the next 8 hours.
- Oral formulations are available and can be used for menorrhagia.
- For dental bleeding/epistaxis you can use 500mg of the IV solution to soak packing/gauze.
1. Andreoli, CM, Gardiner, MF. Traumatic hyphema: Management. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 2, 2017.)
2. Colwell, C. Initial evaluation and management of shock in adult trauma. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 2, 2017.)
3. DeWeert, Daniel, and Elise Lovell. "ED CRASH Course: TXA MATTERS!" Emdocs. N.p., 21 Mar. 2016. Web. 02 Feb. 2017.
4. Saltzman, JR. Approach to acute upper gastrointestinal bleeding in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 2, 2017.)
5. Zacur, HA. Managing an episode of severe or prolonged uterine bleeding. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 2, 2017.)
6. Calvo GS et al. Inhaled Tranexamic Acid as an Alternative for Hemoptysis Treatment. Chest 2016; 149(2): 604.