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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 limiting fibrin degradation and preserving clot stability.
## Primary Indications
* **Hemorrhage Control:** Trauma-associated hemorrhage (CRASH-2/MATTERS protocols) and postpartum hemorrhage.
* **Surgical Hemostasis:** Reduction of blood loss in orthopedic, cardiac, and dental procedures.
* **Other:** Menorrhagia, hereditary angioedema (prophylaxis), and epistaxis.
## Adult Dosing
* **Trauma (CRASH-2 protocol):** 1 gram IV bolus over 10 minutes, followed by 1 gram IV infusion over 8 hours. Administer as soon as possible (ideally <3 hours post-injury).
* **Postpartum Hemorrhage:** 1 gram IV bolus; a second 1 gram dose may be given if bleeding persists after 30 minutes.
* **Menorrhagia:** 1.3 grams orally three times daily for up to 5 days during menstruation.
* **Dental extraction (in hemophiliacs):** 25 mg/kg IV immediately pre-op, followed by 25 mg/kg oral/IV every 6–8 hours for 2–8 days.
## Pediatric Dosing
* **Trauma:** 15–30 mg/kg IV bolus (max 1 gram), followed by 2 mg/kg/hour infusion for 8 hours (or total 8-hour dose per institutional trauma guidelines).
* **General/Surgery:** Dosing is highly variable and protocol-dependent; generally 10 mg/kg IV every 6–8 hours depending on age and indication. Consult pediatric-specific formularies.
## Dose Adjustments
* **Renal Impairment:** Reduce dose in patients with CrCl < 50 mL/min.
* CrCl 30–50 mL/min: 50% of the standard dose.
* CrCl 10–30 mL/min: 25% of the standard dose.
* CrCl < 10 mL/min: 10% of the standard dose.
* **Hepatic Impairment:** No specific adjustment required; use with caution.
## Contraindications
* **History of VTE:** Active thromboembolic disease (DVT, PE, cerebral thrombosis).
* **Hypersensitivity:** Known serious allergy to tranexamic acid.
* **DIC:** Disseminated intravascular coagulation (unless underlying cause is primary fibrinolysis).
* **Color Vision Defect:** Acquired defects may interfere with monitoring for retinotoxicity (long-term use).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thromboembolic events (PE, DVT, MI, stroke), seizures (especially with rapid IV push or high doses), allergic reactions, visual disturbances/retinal changes.
## Key Drug Interactions
* **Thromboembolic agents:** Risk of thrombosis is significantly increased when combined with Factor IX complex concentrates or anti-inhibitor coagulant complexes.
* **Estrogens:** Increased risk of thrombosis when used concomitantly.
## Monitoring
* **Neurological:** Monitor for seizure activity, particularly in neurosurgical patients or those receiving high doses.
* **Vascular:** Monitor for clinical signs of DVT/PE (e.g., unilateral limb swelling, dyspnea, chest pain).
* **Ophthalmologic:** Routine eye exams (color vision/fundus) for chronic, long-term (>1 month) administration.
## Clinical Pearls
* **Rapid Administration Risk:** Rapid IV injection can cause hypotension; always infuse over at least 10 minutes.
* **"Golden Hour":** Benefit in trauma is time-dependent. Efficacy declines rapidly if administered more than 3 hours after injury.
* **Local Protocols:** Hospital-specific trauma guidelines may supersede standard literature; always verify the current institutional protocol for massive transfusion or surgery.
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**Educational Disclaimer:** This information is for educational purposes only. Drug dosing, indications, and safety information change frequently. Always consult the most current manufacturer prescribing information, institutional protocols, and official electronic medical records before prescribing or administering medication.
