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# Tranexamic Acid ## Overview Tranexamic acid (TXA) is a synthetic lysine analog that acts as a potent antifibrinolytic agent. It competitively inhibits the activation of plasminogen to plasmin, thereby preventing the degradation of fibrin clots. ## Primary Indications * **Trauma-associated hemorrhage:** Management of severe bleeding (CRASH-2/MATTERS protocols). * **Postpartum hemorrhage (PPH):** Treatment of uterine bleeding. * **Surgical bleeding:** Prophylaxis or treatment in cardiac, orthopedic, or spinal surgery. * **Hereditary angioedema:** Short-term prophylaxis for dental or minor surgical procedures. * **Menorrhagia:** Treatment of heavy menstrual bleeding. ## Adult Dosing * **Trauma (CRASH-2 protocol):** Loading dose of 1 g IV over 10 minutes, followed by an IV infusion of 1 g over 8 hours. Administer as soon as possible, ideally within 3 hours of injury. * **Postpartum Hemorrhage:** 1 g IV given over 10 minutes. If bleeding continues after 30 minutes or restarts within 24 hours, a second 1 g dose may be administered. * **Menorrhagia:** 1.3 g orally three times daily for up to 5 days during menstruation. * **Surgical Prophylaxis/Local:** Dosing varies widely by surgical specialty; generally 10–30 mg/kg IV bolus or topical application (e.g., in total joint arthroplasty). Always verify against local institutional protocols. ## Pediatric Dosing * **Trauma/Severe Hemorrhage:** 15–20 mg/kg (max 1 g) IV loading dose, followed by 2–10 mg/kg/hour infusion (off-label). * **Hereditary Angioedema:** 25 mg/kg orally three times daily (max 1.5 g/dose). * *Note: Pediatric dosing is highly variable; consult pediatric-specific references or local hospital guidelines.* ## Dose Adjustments * **Renal Impairment:** Requires significant dose reduction in moderate-to-severe renal impairment (CrCl < 50 mL/min) due to renal excretion of the drug. * *CrCl 30–50 mL/min:* Use 50% of the standard dose. * *CrCl 10–30 mL/min:* Use 25% of the standard dose. * *CrCl < 10 mL/min:* Use 10% of the standard dose. * **Hepatic Impairment:** No dose adjustment typically required, but caution is advised in patients with compromised hepatic metabolism. ## Contraindications * **Thromboembolic disease:** History or current diagnosis of DVT, pulmonary embolism, or cerebral thrombosis. * **Active intravascular clotting:** Disseminated intravascular coagulation (DIC). * **Subarachnoid hemorrhage:** In some settings, may be contraindicated due to risk of cerebral ischemia. * **Acquired defective color vision:** Known hypersensitivity to the drug. ## Adverse Effects * **Vascular:** Thromboembolic events (DVT, PE, MI, stroke). * **Neurological:** Seizures (particularly with rapid IV injection or high cumulative doses), headache, dizziness. * **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal pain. * **Ocular:** Visual disturbances (e.g., changes in color vision). ## Key Drug Interactions * **Thrombolytics/Fibrinolytics:** Antagonistic effect; concomitant use significantly increases thrombosis risk. * **Estrogens/Hormonal Contraceptives:** Increased risk of thrombosis when combined with systemic antifibrinolytics. * **Factor IX complex/Prothrombin complex concentrates:** Potential for increased risk of thrombosis. ## Monitoring * **Clinical:** Observe for signs of deep vein thrombosis or pulmonary embolism (e.g., calf pain, shortness of breath, chest pain). * **Neurological:** Monitor for seizures, particularly in surgical patients receiving high doses. * **Renal:** Monitor serum creatinine and renal function if using prolonged therapy. ## Clinical Pearls * **Seizure risk:** Avoid rapid IV administration; slow infusion is critical to reduce cerebral hyperexcitability. * **Utility:** Benefit is most pronounced if administered within the "golden hour" of bleeding onset in trauma; efficacy diminishes significantly after 3 hours post-injury. * **Topical Use:** Increasingly used topically in orthopedic surgery to reduce local blood loss while minimizing systemic exposure, though systemic absorption still occurs. *** *Disclaimer: This information is for educational purposes for healthcare professionals. Clinical protocols vary; always verify current prescribing information, institutional guidelines, and drug interactions using up-to-date regional resources (e.g., Lexicomp, UpToDate, or the local drug formulary) before administration.*