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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is a synthetic lysine analogue that acts as an antifibrinolytic agent by competitively inhibiting the activation of plasminogen to plasmin. This prevents the degradation of fibrin clots, thereby stabilizing hemostasis.
## Primary Indications
* Treatment/prevention of excessive bleeding in trauma (e.g., CRASH-2 protocol).
* Postpartum hemorrhage (WOMAN trial protocol).
* Reduction of bleeding in patients with hemophilia undergoing dental surgery.
* Heavy menstrual bleeding.
* Cardiac surgery (off-label).
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 1 g IV bolus over 10 minutes, followed by an infusion of 1 g over 8 hours (or 1 g IV every 6–8 hours). Ideally administered within 3 hours of injury.
* **Heavy Menstrual Bleeding:** 1.3 g orally three times daily for up to 5 days during menstruation.
* **Dental/Surgical Prophylaxis:** 10 mg/kg IV pre-operatively, followed by 25 mg/kg orally or IV 3–4 times daily for 2–8 days.
## Pediatric Dosing
* **Trauma/Hemorrhage:** 15–20 mg/kg IV bolus (max 1 g), followed by an infusion of 2–10 mg/kg/hour.
* **Note:** Pediatric dosing is highly protocol-dependent; verify against institutional guidelines.
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in moderate to severe impairment (CrCl < 50 mL/min).
* CrCl 30–50 mL/min: Reduce dose by 50% or increase dosing interval.
* CrCl < 30 mL/min: Reduce dose by 75% or increase interval significantly.
* **Hepatic Impairment:** No specific adjustment necessary.
## Contraindications
* Hypersensitivity to TXA.
* Active intravascular clotting (thromboembolic disease).
* History of venous or arterial thrombosis.
* Subarachnoid hemorrhage (risk of cerebral ischemia/vasospasm).
* Color vision defects (impairs discrimination).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (particularly with rapid IV infusion or high doses), visual disturbances (retinal artery occlusion).
## Key Drug Interactions
* **Factor IX complex/Prothrombin complex concentrates:** Increased risk of thrombotic complications; administer cautiously.
* **Hormonal contraceptives:** Potential increased risk of thrombosis when used concurrently.
## Monitoring
* Monitor hemoglobin/hematocrit and blood loss.
* Assess for clinical signs of thrombosis (pedal edema, chest pain, dyspnea).
* Monitor renal function in patients with pre-existing impairment.
* Visual examinations if long-term treatment is initiated.
## Clinical Pearls
* **Seizure Risk:** Rapid IV injection can trigger seizures; always adhere to the recommended 10-minute infusion window for bolus doses.
* **"Time is Tissue":** In trauma scenarios, the efficacy of TXA decreases significantly if administered more than 3 hours after injury.
* **Stability:** Once diluted for IV infusion, check specific product labeling (often stable for 24 hours at room temperature).
* **Consult Local Protocol:** Many trauma centers utilize weight-based adjustments or specific standardized order sets that may differ from general package inserts.
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**Educational Disclaimer:** This information is for educational purposes only. Always verify drug dosages, contraindications, and potential drug interactions with current institutional protocols, primary literature, and the official FDA prescribing information before administration.
