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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, thereby preventing fibrin degradation.
## Primary Indications
* Treatment/prophylaxis of hemorrhage associated with excessive fibrinolysis.
* Trauma-related hemorrhage (CRASH-2 protocol).
* Heavy menstrual bleeding.
* Prophylaxis in hereditary angioedema.
* Off-label: Postpartum hemorrhage, orthopedic surgery, traumatic brain injury (under clinical investigation).
## Adult Dosing
* **Acute Hemorrhage/Trauma:** Loading dose of 1 g IV over 10 minutes, followed by a continuous infusion of 1 g over 8 hours (dependent on local institutional protocol).
* **Heavy Menstrual Bleeding:** 1,300 mg orally three times daily for up to 5 days during menstruation.
* **Hereditary Angioedema:** 1–1.5 g orally 2–3 times daily.
## Pediatric Dosing
* **Trauma/Hemorrhage:** Weight-based dosing is typically 15–20 mg/kg IV loading dose, followed by 2–5 mg/kg/hr infusion (verify local trauma center protocols as these vary widely based on clinical context).
* **Hereditary Angioedema:** 10 mg/kg orally 2–3 times daily (max 1.5 g per dose).
## Dose Adjustments
* **Renal Impairment:** Requires significant reduction in frequency or dose based on creatinine clearance (CrCl). If CrCl < 50 mL/min, use caution; avoid or adjust dosing interval if CrCl < 10–30 mL/min.
* **Hepatic Impairment:** No formal adjustment guidelines exist; use with caution.
## Contraindications
* Active intravascular clotting (thrombosis).
* History of thromboembolic disease (DVT, PE, cerebral thrombosis).
* Subarachnoid hemorrhage (risk of cerebral ischemia/infarction).
* Hypersensitivity to TXA.
* Acquired defective color vision.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache.
* **Serious:** Thromboembolic events (PE, DVT, MI, stroke), seizures (particularly with high doses or rapid IV administration), visual disturbances (retinal artery/vein obstruction), allergic reactions.
## Key Drug Interactions
* **Hormonal Contraceptives:** May increase risk of thrombosis when combined.
* **Thrombolytic Agents:** Concomitant use with alteplase/tenecteplase will neutralize the effect of the thrombolytic.
* **Estrogens:** Increased risk of thrombosis.
## Monitoring
* **Clinical:** Monitor for signs of venous or arterial thrombosis (e.g., limb swelling, chest pain, dyspnea).
* **Ophthalmological:** Periodic eye exams if prolonged therapy is required (though evidence for routine screening is limited).
* **Renal:** Monitor serum creatinine/CrCl when initiating and during prolonged therapy.
## Clinical Pearls
* **Rate Matters:** Rapid IV injection is associated with hypotension and seizures; always infuse over the recommended timeframe.
* **Seizure Risk:** High doses, particularly in neurosurgical and cardiac procedures, significantly increase the risk of postoperative seizures.
* **Pregnancy:** Category B. Generally considered safe for short-term use in obstetric hemorrhage, but balancing benefits vs. risk of maternal thrombosis is required.
* **Local Protocols:** Significant variability exists in trauma protocols (CRASH-2 vs. PATCH-Trauma); always consult your institution’s trauma guidelines.
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*Disclaimer: This information is for educational purposes for healthcare professionals. Dosing, contraindications, and clinical protocols may change; verify all orders against the most current institutional guidelines and FDA-approved prescribing information before administration.*
