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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, thereby preventing the breakdown of fibrin clots.
## Primary Indications
* Treatment/prophylaxis of hemorrhage in hemophilia (dental surgery).
* Heavy menstrual bleeding (menorrhagia).
* Trauma-related hemorrhage (CRASH-2 protocol).
* Surgical prophylaxis (cardiac, orthopedic, prostatectomy).
* Epistaxis and postpartum hemorrhage (off-label).
## Adult Dosing
* **Heavy Menstrual Bleeding:** 1,300 mg orally three times daily for up to 5 days during menstruation.
* **Trauma (CRASH-2):** 1 gram IV bolus over 10 minutes, followed by 1 gram IV infusion over 8 hours.
* **Dental Extraction in Hemophiliacs:** 10 mg/kg IV immediately before surgery, followed by 25 mg/kg orally three to four times daily for 2–8 days.
* **Postpartum Hemorrhage:** 1 gram IV over 10 minutes (repeat 1 gram dose if bleeding continues after 30 minutes).
## Pediatric Dosing
* **Hemophilia/Surgery:** 10 mg/kg IV (pre-op), followed by 25 mg/kg orally three times daily.
* **Trauma/Acute Bleeding:** 15 mg/kg IV bolus (max 1 gram), followed by 2 mg/kg/hour infusion (off-label; follow institutional protocol).
## Dose Adjustments
* **Renal Impairment:** Required for patients with CrCl < 50 mL/min.
* CrCl 30–50 mL/min: 10 mg/kg IV twice daily or 10 mg/kg oral twice daily.
* CrCl 10–30 mL/min: 10 mg/kg IV once daily or 10 mg/kg oral once daily.
* CrCl < 10 mL/min: 5 mg/kg IV or oral once daily.
* **Hepatic Impairment:** No standard adjustment required, but use with caution.
## Contraindications
* Active intravascular clotting (e.g., DVT, pulmonary embolism).
* Acquired defective color vision (prevents monitoring of retinal toxicities).
* Subarachnoid hemorrhage (risk of cerebral ischemia/seizures).
* Hypersensitivity to TXA.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache.
* **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (particularly with rapid IV administration or high doses), visual disturbances (color vision changes, retinal artery occlusion), and hypersensitivity reactions.
## Key Drug Interactions
* **Factor IX complex/Prothrombin complex concentrates:** Increased risk of thrombosis.
* **Estrogens/Oral Contraceptives:** May increase susceptibility to thromboembolic events.
* **Thrombolytics:** Antagonistic effect; do not administer concurrently.
## Monitoring
* **Clinical:** Monitor for signs of venous/arterial thromboembolism (leg pain/swelling, chest pain, dyspnea).
* **Renal:** Monitor serum creatinine in patients with baseline renal impairment.
* **Ophthalmologic:** Baseline and periodic eye exams if on long-term therapy.
## Clinical Pearls
* **Seizure Risk:** Rapid IV injection can trigger seizures; always infuse over at least 10 minutes.
* **Not a Replacement for Source Control:** TXA stabilizes clots but does not fix the anatomical source of bleeding.
* **Administration:** Oral tablets should be swallowed whole; do not crush or chew.
* **Standardization:** Always verify doses against current hospital protocols, especially in trauma or pediatric populations, as weight-based dosing varies by region and indication.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines and drug information are subject to change. Always verify specific dosing, safety profiles, and institutional protocols with current prescribing information, such as the FDA-approved label or a clinical drug database before administration.
