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# Tranexamic Acid (TXA)
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, preventing the degradation of fibrin clots. It is available as oral tablets and intravenous (IV) solution.
## Primary Indications
* **Hemorrhage management:** Trauma-related bleeding (CRASH-2 protocol), postpartum hemorrhage, and perioperative blood loss.
* **Mucosal bleeding:** Menorrhagia, epistaxis, and dental procedures in patients with coagulopathies.
* **Hereditary angioedema:** Prophylactic management.
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 1 g IV loading dose over 10 minutes, followed by 1 g IV infusion over 8 hours. Administer within 3 hours of injury.
* **Postpartum Hemorrhage:** 1 g IV slow push; may repeat once if bleeding continues after 30 minutes.
* **Menorrhagia:** 1.3 g orally three times daily for up to 5 days during menstruation.
## Pediatric Dosing
* **Trauma:** 15–30 mg/kg IV bolus (max 1 g), followed by 2–5 mg/kg/hour infusion per institutional site-specific trauma protocol.
* **General/Off-label use:** Dosing varies significantly by indication; consult institutional guidelines for pediatric hematology or surgical protocols.
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in patients with CrCl < 50 mL/min.
* CrCl 30–50 mL/min: 50% of standard dose or increased interval.
* CrCl < 30 mL/min: Use caution; 25% of standard dose or extended intervals.
* **Hepatic Impairment:** No specific adjustment required, but use with caution.
## Contraindications
* Active intravascular clotting (thromboembolic disease).
* History of venous or arterial thrombosis.
* Subarachnoid hemorrhage (due to risk of cerebral ischemia/vasospasm).
* Color vision defects (acquired).
* Hypersensitivity to TXA.
## Adverse Effects
* **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal pain.
* **Vascular:** Thromboembolic events (DVT, PE, MI, stroke).
* **Ocular:** Visual disturbances (color vision changes).
* **Neurological:** Seizures (particularly with high-dose IV administration or intrathecal misadministration).
## Key Drug Interactions
* **Thrombolytics:** Concurrent use may antagonize the effect of thrombolytic therapy.
* **Estrogens/Hormonal Contraceptives:** May increase the risk of thrombosis when used concomitantly.
* **Prothrombin Complex Concentrates (PCCs) or Factor IX:** Increased risk of thrombosis.
## Monitoring
* Monitor for signs of thromboembolism (leg swelling, chest pain, dyspnea).
* Monitor hemoglobin/hematocrit and blood pressure.
* Ophthalmologic exams if treatment is long-term.
* Renal function (BUN/SCr).
## Clinical Pearls
* **Administration:** Never administer IV push too rapidly to avoid hypotension.
* **Fatal Error:** Direct intrathecal infusion is FATAL.
* **Off-label:** Commonly used in topical applications for orthopedic surgeries; ensure specific local protocols are followed for concentration and volume.
* **Therapeutic Window:** Effectiveness is significantly reduced if administered > 3 hours after injury in trauma settings.
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**Educational Disclaimer:** This information is for educational purposes only and does not constitute medical advice. Prescribing information, local hospital protocols, and patient-specific factors (e.g., renal function, concomitant medications) may influence dosing. Always verify current clinical guidelines and the manufacturer's prescribing information before administration.
