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# Tranexamic Acid (TXA)
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, thereby preventing fibrin degradation. It is a synthetic lysine analog.
## Primary Indications
* **Trauma:** Reduction of mortality in patients with significant hemorrhage (CRASH-2 protocol).
* **Surgery:** Prophylaxis or treatment of hemorrhage in cardiac, orthopedic, or complex surgical procedures.
* **Obstetrics:** Treatment of postpartum hemorrhage (WOMAN trial).
* **Hemorrhagic Conditions:** Management of menorrhagia, epistaxis, or hereditary angioedema.
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 1g IV bolus over 10 minutes, followed by 1g IV infusion over 8 hours. Administer as soon as possible, ideally within 3 hours of injury.
* **Postpartum Hemorrhage:** 1g IV bolus. May repeat 1g IV if bleeding continues after 30 minutes.
* **Menorrhagia:** 1.3g orally three times daily for up to 5 days during menstruation.
## Pediatric Dosing
* **Trauma/General Hemorrhage:** 10–20 mg/kg (max 1g) IV bolus, followed by 5–10 mg/kg/hour infusion typically lasting 8 hours.
* *Note: Pediatric dosing varies significantly by institution; local hematology or institutional trauma protocols must be consulted.*
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in moderate-to-severe renal impairment (CrCl < 50 mL/min).
* CrCl 30–50 mL/min: Reduce dose by 50%.
* CrCl 10–30 mL/min: Reduce dose by 75%.
* CrCl < 10 mL/min: Dose as 10% of standard dose.
* **Hepatic Impairment:** No standard adjustment required, but use with caution.
## Contraindications
* Active intravascular clotting (thromboembolic disease).
* History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
* Subarachnoid hemorrhage (due to risk of cerebral ischemia/seizure).
* Known hypersensitivity to tranexamic acid.
* Disseminated intravascular coagulation (DIC).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thromboembolic events (DVT/PE, myocardial infarction, stroke), seizures (particularly with rapid IV injection or high doses).
* **Ocular:** Visual color changes or disturbances (rare).
## Key Drug Interactions
* **Thrombolytics:** Concurrent use with thrombolytics (e.g., alteplase) may neutralize the effect of both agents.
* **Estrogens/Hormonal Contraceptives:** May increase the risk of thrombosis if used concomitantly.
* **Factor IX complex/Antinhibitor Coagulant Concentrates:** Increased risk of thrombosis.
## Monitoring
* **Clinical:** Monitor for signs of thromboembolism (e.g., chest pain, dyspnea, unilateral limb swelling).
* **Neurological:** Monitor for seizure activity, especially if high doses are administered.
* **Renal:** Monitor serum creatinine/BUN in patients with known insufficiency.
## Clinical Pearls
* **Administration:** Rapid IV injection can cause hypotension; administer boluses over at least 10 minutes to minimize risk.
* **Time Sensitivity:** Efficacy in trauma is highly time-dependent; benefit decreases significantly if administered beyond 3 hours of injury.
* **Color Vision:** If visual changes occur while on long-term therapy, discontinue immediately and perform an ophthalmologic exam.
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**Disclaimer:** This information is for educational purposes only. Always consult current institutional protocols and the most recent package insert or clinical resources (e.g., Lexicomp, UpToDate) before prescribing or administering medication.
