Tranexamic acid (TXA) use is set to widen in England and Wales under new draft guidance from the National Institute for Health and Care Excellence (NICE).

NICE recommends offering TXA before any procedure in which bleeding is expected and before the skin or mucosa is breached. The aim is to reduce perioperative bleeding and the need for transfusions.

The guidance applies to patients aged 1 year or older. It marks a substantial shift from the 2015 recommendations, which limited routine TXA use to operations with anticipated blood loss greater than 500 mL.

Outside the operating theatre, TXA should be offered to adults when anticipated blood loss exceeds 500 mL and considered for children aged 1-15 years when expected loss exceeds 10% of blood volume. Procedures where bleeding is not consistently expected, such as corneal surgery and some invasive diagnostics including hysteroscopy, are excluded.

Evidence and Clinical Impact

The committee reviewed evidence showing that TXA reduces transfusions and shortens hospital stays for patients having surgery with anticipated minor bleeding. Safety data showed lower all-cause mortality and a reduced need for repeat operations. Thromboembolic events occurred in less than 0.1% of patients.

Clinical benefits included reduced postoperative pain, particularly for procedures involving small cavities, lower haematoma and infection rates, and earlier resumption of antiplatelet and anticoagulant medications.

Economic modelling found TXA to be cost-effective due to shorter hospital stays and fewer transfusions, even when quality-of-life impacts were excluded from calculations. TXA remained cost-effective for surgical procedures with a transfusion probability of 2% or higher. Additional advantages not captured in economic models include improved visibility for surgeons due to less bleeding, decreased need for surgical drains, lower infection risk, and reduced post-operative bleeding.

Dosing and Administration Protocols

For adults, the first dose is given before incision. A typical dose is 1 g by slow intravenous injection. Additional doses may be given intraoperatively depending on procedure length and measured blood loss volume.

For children aged 1-15 years, the recommended first dose is 15 mg/kg, up to a maximum of 1 g by slow intravenous injection. Additional doses may be considered during surgery based on duration and blood loss.

The committee noted that the clinical significance of blood loss differs between children and adults, requiring careful benefit-risk assessment for paediatric patients.

Implementation and Research Priorities

The broadened recommendations are expected to increase TXA use without requiring additional staffing, as theatre teams are already trained to give intravenous medications. 

NICE identified two key research priorities: evaluating clinical and cost-effectiveness of TXA in children and young people undergoing surgery, and the role of TXA in specific vascular procedures. Evidence remains limited in paediatric populations, with only one safety study available.

For young people, the committee made no specific recommendations due to insufficient evidence. It expects clinicians to apply adult recommendations using clinical judgement. Exclusions apply to procedures where bleeding is not reliably expected, including corneal surgery and some invasive diagnostic procedures such as hysteroscopy.