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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is a synthetic lysine analog that acts as a potent antifibrinolytic agent by competitively inhibiting the activation of plasminogen to plasmin. It prevents fibrin degradation and stabilizes clot formation.
## Primary Indications
* **Trauma:** Management of hemorrhage in severely injured patients (CRASH-2 protocol).
* **Surgery:** Prophylaxis or treatment of hemorrhage in cardiac, orthopedic, or spinal surgery.
* **Menorrhagia:** Treatment of cyclic heavy menstrual bleeding.
* **Epistaxis/Dental:** Topical or oral use for localized bleeding.
## Adult Dosing
* **Trauma (Hemorrhage):** 1 g IV loading dose over 10 minutes, followed by 1 g IV infusion over 8 hours. Administer as soon as possible, ideally within 3 hours of injury.
* **Menorrhagia:** 1,300 mg orally three times daily for a maximum of 5 days during menstruation.
* **Surgery (Dosing varies by protocol):** 10–15 mg/kg IV bolus, followed by 1–10 mg/kg/hour infusion, or 1 g IV prior to incision/tourniquet release.
## Pediatric Dosing
* **Trauma:** Off-label. Consult local institutional protocols. Common range: 10–20 mg/kg IV bolus, followed by 2–10 mg/kg/hour infusion.
* **Hemophilia/Dental:** 25 mg/kg orally every 8 hours.
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in patients with CrCl <50 mL/min.
* CrCl 30–50 mL/min: 1 g IV every 12 hours (or 50% of standard dose).
* CrCl <30 mL/min: 1 g IV every 24 hours (or 25% of standard dose).
* **Hepatic Impairment:** No specific adjustment required.
## Contraindications
* Active intravascular clotting (thromboembolic disease).
* History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
* Acquired defective color vision (prevents monitoring of optic nerve toxicity).
* Subarachnoid hemorrhage (risk of cerebral ischemia/seizure).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal cramps (dose-related).
* **Serious:** Thromboembolic events (PE, DVT, myocardial infarction, stroke), seizures (especially with rapid IV push or high accumulation in renal failure), and visual disturbances (retinal artery/vein occlusion).
## Key Drug Interactions
* **Thrombolytics (e.g., tPA):** Antagonistic effects; avoid concurrent use.
* **Estrogens/Oral Contraceptives:** Potential increased risk of venous thromboembolism (VTE).
* **Factor IX complex/Prothrombin complex concentrates:** High risk of thrombotic complications if combined.
## Monitoring
* Monitor for signs of thromboembolism (e.g., leg pain/swelling, chest pain, dyspnea).
* Renal function (CrCl) must be assessed to determine need for dose reduction.
* Neurological status, especially with high doses.
## Clinical Pearls
* **Seizure Warning:** Rapid IV administration has been associated with increased seizure activity; always utilize the recommended infusion times.
* **Administration:** Never administer via neuraxial routes (spinal/epidural); this is associated with severe, often fatal, neurotoxicity and seizures.
* **Topical Use:** Off-label topical application (e.g., oral rinses for dental procedures or soaked dressings for epistaxis) is common and generally has low systemic absorption.
* **Timing:** For trauma, efficacy drops significantly if administered >3 hours post-injury.
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**Disclaimer:** This information is for educational purposes only. Clinical protocols vary by institution. Always verify dosages, contraindications, and drug interactions against the most current FDA-approved labeling or your institutional pharmacy formulary before prescribing or administering medication.
