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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is a synthetic lysine analog 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
* **Hemorrhage:** Prophylaxis and treatment of heavy menstrual bleeding, cyclic heavy menstrual bleeding, and trauma-associated hemorrhage.
* **Surgery:** Reduction of blood loss during cardiac surgery, orthopedic procedures, and spinal surgery.
* **Dental:** Management of hemorrhage in hemophiliacs undergoing dental extraction.
## Adult Dosing
* **Trauma-Associated Hemorrhage:** 1 g IV loading dose over 10 minutes, followed by 1 g IV infusion over 8 hours. Administer as soon as possible, ideally within 3 hours of injury.
* **Heavy Menstrual Bleeding:** 1.3 g orally three times daily (3.9 g total daily dose) for up to 5 days during menstruation.
* **Dental Surgery (Hemophiliacs):** 10 mg/kg IV immediately prior to surgery, followed by 25 mg/kg orally three times daily for 2–8 days.
## Pediatric Dosing
* **Trauma (Off-label/CRASH-2 protocol adaptation):** 15 mg/kg (max 1 g) IV loading dose, followed by 2 mg/kg/hour infusion for 8 hours. Note: Follow local institutional protocols for trauma resuscitation.
* **Hemophilia/Dental:** 25 mg/kg orally three times daily for 2–8 days.
## Dose Adjustments
* **Renal Impairment:** Requires significant dose reduction based on creatinine clearance (CrCl).
* CrCl 30–50 mL/min: 50% of the standard dose.
* CrCl 10–30 mL/min: 25% of the standard dose.
* CrCl <10 mL/min: 10% of the standard dose.
* **Hepatic Impairment:** No specific dose adjustment guidelines; use with caution.
## Contraindications
* Active intravascular clotting.
* History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
* Subarachnoid hemorrhage (due to risk of cerebral edema/seizures).
* Acquired defective color vision (prevents monitoring of retinal toxicity).
* Hypersensitivity to TXA.
## Adverse Effects
* **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal pain.
* **Neurological:** Seizures (especially with high doses or rapid IV administration).
* **Vascular:** Thromboembolic events (DVT, PE, MI, stroke).
* **Ocular:** Visual disturbances (retinal artery/vein occlusion).
## Key Drug Interactions
* **Thrombolytics:** Concurrent use may negate the effects of thrombolytic therapy or increase risk of systemic thrombosis.
* **Estrogen-containing contraceptives:** Increased risk of thrombosis when combined with antifibrinolytics.
* **Factor IX complex/Antinhibitor coagulant concentrates:** Potential increase in risk of thrombosis.
## Monitoring
* **Safety:** Monitor for signs of thromboembolism (unilateral leg swelling, chest pain, dyspnea).
* **Neurological:** Monitor for seizures, particularly if high IV doses are given.
* **Visual:** Patients reporting changes in vision should undergo an ophthalmologic evaluation.
* **Renal:** Monitor serum creatinine/CrCl to guide dosage adjustments.
## Clinical Pearls
* **Administration Safety:** Never administer TXA via intrathecal or epidural routes; it can cause severe neurotoxicity and death.
* **Trauma window:** TXA is most effective when administered within the first 3 hours of injury; benefit diminishes after 3 hours and may cause harm if administered after 3 hours in trauma settings.
* **Seizure Risk:** Rapid IV injection can increase seizure risk; ensure the loading dose is infused over at least 10 minutes.
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**Disclaimer:** This information is for educational purposes only. Dosing and protocols may vary based on institutional standards and clinical context. Always verify the most current prescribing information and local guidelines before administering medication.
