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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 breakdown of fibrin clots. ## Primary Indications * **Trauma:** Management of severe hemorrhage (CRASH-2 protocol). * **Surgery:** Reduction of blood loss in major orthopedic, cardiac, and spinal surgeries. * **Obstetrics:** Treatment of postpartum hemorrhage. * **Other:** Menorrhagia, epistaxis, or hereditary angioedema (off-label). ## Adult Dosing * **Trauma (CRASH-2):** 1 gram IV bolus given over 10 minutes, followed by 1 gram IV infusion over 8 hours. Administer as soon as possible (within 3 hours of injury). * **Surgery:** Dosing varies widely by protocol. Common range: 10–30 mg/kg IV loading dose, sometimes followed by an infusion of 1–5 mg/kg/hour. * **Menorrhagia:** 1.3 grams orally three times daily for up to 5 days during menstruation. ## Pediatric Dosing * **Trauma:** 15 mg/kg IV loading dose (max 1 gram), followed by 2 mg/kg/hour infusion for 8 hours (dependent on institutional protocol). * **General Surgery/Hemostasis:** 10–20 mg/kg IV loading dose is commonly utilized. *Pediatric dosing lacks universal standardization; consult local clinical guidelines.* ## Dose Adjustments * **Renal Impairment:** Requires dose reduction or longer interval based on creatinine clearance (CrCl). * CrCl 30–50 mL/min: 10 mg/kg IV twice daily or 50% of the standard dose. * CrCl 10–30 mL/min: 10 mg/kg IV once daily or 25% of the standard dose. * CrCl <10 mL/min: 10 mg/kg IV every 48 hours or 5 mg/kg IV every 24 hours. * **Hepatic Impairment:** No formal dosage adjustments provided, but use with caution. ## Contraindications * Hypersensitivity to TXA. * Active intravascular clotting (thromboembolic disease). * History of venous or arterial thrombosis. * Acquired disturbances of color vision (precludes monitoring for ocular toxicity). * Subarachnoid hemorrhage (theoretical risk of cerebral vasospasm). ## Adverse Effects * **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal pain (more common with oral dosing). * **Vascular:** Thromboembolic events (DVT, PE, MI, stroke). * **Neurological:** Seizures (particularly with high doses or rapid IV administration). * **Ocular:** Visual color changes or retinal vein occlusion. * **Hypersensitivity:** Anaphylaxis (rare). ## Key Drug Interactions * **Combined Hormonal Contraceptives:** Increased risk of thrombosis. * **Prothrombin Complex Concentrates (PCCs) / Factor IX:** Concurrent use may increase the risk of thrombotic events. * **Thrombolytics:** Concurrent use negates effects of both agents. ## Monitoring * **Clinical:** Monitor for signs of deep vein thrombosis, pulmonary embolism, or neurological changes. * **Renal:** Monitor renal function in patients receiving repeated or maintenance doses. * **Ocular:** Baseline and periodic eye exams if long-term treatment is initiated. ## Clinical Pearls * **Seizure Risk:** Avoid rapid IV push; administer slowly to reduce seizure risk, particularly in cardiac surgery patients. * **Timing:** TXA is most effective when administered early; efficacy significantly decreases if given >3 hours post-injury. * **Formulation:** TXA is for IV or oral use; it is **not** intended for intrathecal administration, which can cause severe neurotoxicity and fatality. Always verify the preparation. *** **Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines vary by institution and patient population. Always consult the latest institutional protocols and the manufacturer's official prescribing information before administering any medication.