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# Tranexamic acid
## Overview
Tranexamic acid is a synthetic antifibrinolytic agent that competitively inhibits plasminogen activation, thereby stabilizing clot formation. It is available in oral, intravenous, and topical formulations.
## Primary Indications
- **Major trauma** with or at risk of significant hemorrhage (CRASH-2 trial)
- **Menorrhagia** (heavy menstrual bleeding)
- **Elective surgery** (cardiac, orthopedic, spinal, craniofacial) to reduce blood loss and transfusion need
- **Upper gastrointestinal bleeding** (HALT-IT trial)
- **Dental procedures** in patients on anticoagulants (topical or oral)
- **Hereditary angioedema** (prophylaxis and treatment)
## Adult Dosing
- **Trauma/hemorrhage**: 1 g IV over 10 minutes, then 1 g IV infusion over 8 hours (within 3 hours of injury)
- **Menorrhagia**: 1 g orally 3 times daily for up to 5 days during menstruation
- **Upper GI bleeding**: 1 g IV over 10 minutes, then 3 g IV infusion over 24 hours
- **Surgical prophylaxis**: 1 g IV at induction (or 10–20 mg/kg); may repeat once if needed
- **Hereditary angioedema**: 1–1.5 g orally 2–3 times daily (prophylaxis); 1 g IV for acute attacks
## Pediatric Dosing
- **Surgical prophylaxis**: 10–15 mg/kg IV (max 1 g) at induction; may repeat once
- **Trauma/hemorrhage**: 15 mg/kg IV (max 1 g) over 10 minutes, then 2 mg/kg/hour infusion for 8 hours (limited evidence; follow local protocol)
- **Menorrhagia** (adolescents): 1 g orally 3 times daily for up to 5 days (same as adult)
- **Dental procedures**: 15–25 mg/kg orally or IV (max 1.5 g) 2 hours before procedure
## Dose Adjustments
- **Renal impairment**: Reduce dose in moderate-to-severe impairment (CrCl <30 mL/min): 10 mg/kg IV once daily, or 15 mg/kg orally every 12–24 hours. Avoid in severe renal failure unless benefit outweighs risk.
- **Hepatic impairment**: No specific adjustment required.
## Contraindications
- Active thromboembolic disease (e.g., DVT, PE, stroke)
- History of thrombosis or hypercoagulable state
- Subarachnoid hemorrhage (risk of cerebral edema/infarction)
- Severe renal impairment (CrCl <15 mL/min) unless dialysis
- Hypersensitivity to tranexamic acid
## Adverse Effects
- **Common**: Nausea, vomiting, diarrhea, dizziness, hypotension (with rapid IV)
- **Serious**: Thromboembolic events (rare), seizures (high-dose IV, especially cardiac surgery), anaphylaxis, visual disturbances (require discontinuation)
- **Note**: Risk of seizures increases with doses >2 g IV in cardiac surgery
## Key Drug Interactions
- **Anticoagulants/antiplatelets**: Increased bleeding risk if used with warfarin, heparin, DOACs, aspirin—monitor
- **Factor IX complex concentrates**: Increased thrombotic risk
- **Oral contraceptives/hormonal therapy**: Theoretical increased thrombotic risk (limited evidence)
- **Tretinoin**: Increased risk of thrombosis (avoid combination)
## Monitoring
- Renal function before and during therapy (especially in elderly or renal impairment)
- Signs/symptoms of thrombosis (chest pain, leg swelling, dyspnea, neurological changes)
- Visual changes (discontinue if occur)
- For menorrhagia: assess response after 3 cycles; consider alternative if ineffective
## Clinical Pearls
- **Timing is critical**: In trauma, give within 3 hours of injury for mortality benefit; after 3 hours, harm may outweigh benefit.
- **Topical use**: 100 mg/mL solution applied as mouthwash (5–10 mL for 2 minutes) reduces bleeding in dental procedures on anticoagulants.
- **IV compatibility**: Compatible with most crystalloids; do not mix with blood products or solutions containing penicillin.
- **Seizure risk**: Use lowest effective dose in cardiac surgery; avoid doses >2 g IV.
- **Pregnancy**: Limited data; generally avoided unless clear benefit (e.g., postpartum hemorrhage). Use only if clearly needed.
*This information is for educational purposes only. Always verify current prescribing information, local protocols, and individual patient factors before administering tranexamic acid.*
