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# Tranexamic acid
## Overview
Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, thereby preventing the breakdown of fibrin clots.
## Primary Indications
* **Hemorrhage:** Traumatic hemorrhage (CRASH-2 protocol), postpartum hemorrhage, perioperative blood loss reduction.
* **Mucosal bleeding:** Menorrhagia, epistaxis, dental procedures in patients with coagulopathies.
* **Hereditary Angioedema:** Short-term prophylaxis.
## Adult Dosing
* **Trauma/Acute 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.
* **Menorrhagia:** 1.3 g orally TID for up to 5 days during menstruation.
* **Dental/Minor Surgical Bleeding:** 10–15 mg/kg IV or 1–1.5 g orally TID/QID.
## Pediatric Dosing
* **Trauma (Off-label):** 15 mg/kg IV loading dose (max 1 g), followed by 2 mg/kg/hour infusion for 8 hours (or total dose of 2 g).
* **General Hemostasis:** 10 mg/kg IV TID or 25 mg/kg orally TID.
## Dose Adjustments
* **Renal Impairment:** Must be dose-reduced based on creatinine clearance (CrCl).
* CrCl 30–50 mL/min: Reduce dose by 50% or increase dosing interval.
* CrCl <30 mL/min: Reduce dose by 75% or significantly increase interval.
* **Hepatic Impairment:** No specific adjustment necessary as the drug is primarily renally cleared.
## Contraindications
* Active intravascular clotting (thromboembolic disease).
* History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
* Subarachnoid hemorrhage (risk of cerebral ischemia/seizure).
* Acquired defective color vision (cannot distinguish if optic neuropathy occurs).
## Adverse Effects
* **Common:** GI disturbances (nausea, vomiting, diarrhea), headache, sinus/nasal symptoms.
* **Serious:** Thromboembolism (DVT, PE, MI, stroke), seizures (particularly with rapid IV administration or high doses), visual disturbances (retinal artery/vein occlusion).
## Key Drug Interactions
* **Hormonal Contraceptives:** May increase risk of thrombosis when used concurrently.
* **Prothrombin Complex Concentrates/Factor IX:** May increase the risk of thrombosis; generally avoid concomitant use.
* **Thrombolytics:** Direct antagonism; do not administer TXA while on active thrombolytic therapy.
## Monitoring
* **Neurological:** Monitor for seizure activity, especially with high-dose IV administration.
* **Thromboembolic:** Monitor for signs/symptoms of DVT or PE (leg swelling, chest pain, dyspnea).
* **Ophthalmologic:** Baseline and periodic eye exams if long-term treatment is required.
* **Renal:** Monitor serum creatinine/CrCl to guide necessary dose adjustments.
## Clinical Pearls
* **Administration:** IV boluses should be administered slowly over at least 10 minutes to reduce the risk of hypotension and seizures.
* **Timing:** Efficacy is time-dependent; for trauma, administration after 3 hours may increase mortality and is generally not recommended per CRASH-2 data.
* **Protocol Dependency:** Always verify the specific trauma protocol at your institution, as dosing regimens vary between global health systems.
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*Educational Disclaimer: This information is for educational purposes only and does not constitute medical advice. Dosing, contraindications, and drug availability may vary by local practice standards and regional guidelines. Always verify current prescribing information, package inserts, and hospital protocols before administration.*
