Tranexemic Acid is a synthetic, reversible competitive inhibitor to the lysine receptor on plasminogen. TXA prevents plasmin from binding to fibrin, thus reducing fibrinolysis and stabilizing a fibrin clot. The optimal dose for tranexmic acid is matter of debate.
- Rowell et al (JTraumAcuteSurg.2024)did a secondary analysis of Pre Hospital Tranexemic Acid for TBI Trial. The trial included randomized adults with moderate/severe TBI (Glasgow Coma Scale score < 13) and systolic blood pressure ≥ 90 mm Hg within 2 hours of injury to a 2-g out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-g out-of-hospital TXA bolus/1-g in-hospital TXA infusion, or placebo. The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-g TXA bolus group (17%) compared with the other two groups (1-g bolus/1-g infusion 26%, placebo 27%). Study concluded that A 2-g out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing.
- Guyette et al (JAMASurg. 2020) did a multicenter RCT to asses whether a prehospital administration of tranexemic acid lowered 30 day mortality in patients at risk for hemorrhage after trauma. The participants were randomised to tranexemic acid or placebo group. The patients in intervention group received 1gm tranexemic acid bolus en route to hospital was further allocated to three groups :
- Abbreviated Tranexemic acid group : No additional Tranexemic Acid
- Standard Tranexemic Acid regimen : 1 gm IV over 8 hours (Total 2 gm)
- Repeat bolus Tranexemic Acid regimen : 1gm Tranexemic acid IV bolus over 10
- minutes followed by 1gm Tranexemic acid infusion over 8 hours. ( Total 3gm)
- Study found that when comparing tranexamic acid dosing regimens in patients with 30-day mortality outcomes available, mortality rates were 10.0% for placebo, 9.3% for abbreviated, 7.8% for standard, and 7.3% for repeat bolus tranexamic acid groups. Among the prespecified comparisons of each tranexamic acid regimen to placebo, the repeat bolus regimen had lower 30-day mortality after adjusting for site (7.3% vs 10.0%; difference, −2.7%; 95% CI, −5.0% to −0.4%; P = .04). Prespecified dose response analyses demonstrate that receipt of a repeat bolus regimen (3 g of tranexamic acid) results in significantly lower 30-day mortality compared with placebo.
Recommendation
- ATLS 11th Edition recommends both 1gm bolus followed 1 gm over 8 hours and 2 gm IV bolus regimen as safe and efficacious.
Reference
- Guyette FX, Brown JB, Zenati MS, Early-Young BJ, Adams PW, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Forsythe RM, Rosengart MR, Billiar TR, Yealy DM, Peitzman AB, Sperry JL; STAAMP Study Group. Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial. JAMA Surg. 2020 Oct 5;156(1):11–20. doi: 10.1001/jamasurg.2020.4350. Epub ahead of print. Erratum in: JAMA Surg. 2021 Jan 1;156(1):105. doi: 10.1001/jamasurg.2020.5809. PMID: 33016996; PMCID: PMC7536625.
- Rowell S, Meier EN, Hoyos Gomez T, Fleming M, Jui J, Morrison L, Bulger E, Sopko G, Weisfeldt M, Christenson J, Klotz P, McMullan J, Callum J, Sheehan K, Tibbs B, Aufderheide T, Cotton B, Gandhi R, Idris A, Frascone RJ, Ferrara M, Richmond N, Kannas D, Schlamp R, Robinson B, Dries D, Tallon J, Hendrickson A, Gamber M, Garrett J, Simonson R, McKinley WI, Schreiber M. The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: A subgroup analysis from the prehospital TXA for TBI trial. J Trauma Acute Care Surg. 2024 Oct 1;97(4):572-580. doi: 10.1097/TA.0000000000004354. Epub 2024 Apr 30. PMID: 38685481.
