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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 the breakdown of fibrin clots. ## Primary Indications * Treatment/prevention of blood loss in major trauma (CRASH-2 protocol). * Postpartum hemorrhage (WOMAN trial protocol). * Short-term management of hemophilia-associated bleeding. * Heavy menstrual bleeding. * Surgical prophylaxis (e.g., orthopedic, cardiac). ## Adult Dosing * **Trauma/Acute Hemorrhage:** 1 g IV loading dose over 10 minutes, followed by a continuous infusion of 1 g over 8 hours. Administer as soon as possible, ideally within 3 hours of injury. * **Heavy Menstrual Bleeding:** 1.3 g orally three times daily for up to 5 days during menstruation. * **Surgical Prophylaxis:** Varies widely by institutional protocol (typically 10–20 mg/kg IV bolus). ## Pediatric Dosing * **Trauma/Hemorrhage:** 15–20 mg/kg IV loading dose (max 1 g), followed by 2–10 mg/kg/hour infusion, depending on institutional guidelines. * *Note:* Pediatric dosing is highly protocol-dependent; verify with local pediatric pharmacy guidelines. ## Dose Adjustments * **Renal Impairment:** Reduce dose for CrCl <50 mL/min. * CrCl 30–50 mL/min: 10 mg/kg twice daily IV or 15–20 mg/kg orally twice daily. * CrCl 10–30 mL/min: 10 mg/kg daily IV or 15–20 mg/kg once daily orally. * CrCl <10 mL/min: 5 mg/kg daily IV or 15–20 mg/kg every 48 hours orally. ## Contraindications * Active intravascular clotting (thrombosis). * Acquired defective color vision (prevents monitoring of optic nerve toxicity). * History of venous or arterial thrombosis. * Subarachnoid hemorrhage (theoretical risk of cerebral vasospasm). ## Adverse Effects * **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea). * **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (particularly with high doses or rapid administration), and visual disturbances. ## Key Drug Interactions * **Estrogens/Hormonal Contraceptives:** Increased risk of thrombosis. * **Factor IX complex/Prothrombin complex concentrates:** Increased risk of thrombosis; avoid concomitant use unless strictly necessary. * **Thrombolytic agents:** Antagonistic effect; do not use concurrently. ## Monitoring * Monitor for signs of thromboembolism (calf pain, chest pain, dyspnea). * Ophthalmologic exams if treatment exceeds several weeks. * Renal function (BUN/SCr) to guide dosing adjustments. ## Clinical Pearls * **Seizure Risk:** Do not exceed recommended infusion rates. Incorrect administration (especially accidental neuraxial injection) can cause life-threatening seizures. * **Timing:** Efficacy is highly time-dependent in trauma; "Time is blood." Efficacy decreases significantly after 3 hours post-injury. * **Compatibility:** TXA is physically compatible with most common fluids (NS, D5W, LR) but should be checked for Y-site compatibility with specific medications (do not mix with blood products or penicillin). *** *Disclaimer: This information is for educational purposes only. Dosing protocols may vary significantly by institution and clinical context. Always verify current prescribing information, institutional guidelines, and patient-specific factors before administration.*