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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is a synthetic lysine analog that acts as an antifibrinolytic agent by reversibly blocking lysine-binding sites on plasminogen molecules, preventing the formation of plasmin and the subsequent degradation of fibrin clots.
## Primary Indications
* **Trauma:** Prevention/treatment of hemorrhage in severe trauma (CRASH-2 protocol).
* **Surgery:** Reduction of blood loss in surgical procedures (e.g., orthopedic, cardiac).
* **Obstetrics:** Management of postpartum hemorrhage (WOMAN trial).
* **Other:** Heavy menstrual bleeding, hereditary angioedema, and epistaxis.
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 1 g IV loading dose over 10 minutes, followed by 1 g infusion over 8 hours.
* **Heavy Menstrual Bleeding:** 1,300 mg orally three times daily for up to 5 days during menstruation.
* **Surgical Prophylaxis:** Varies by procedure; common range 10–20 mg/kg IV bolus preoperatively, often followed by infusion or additional boluses.
* **Note:** Always consult institutional protocols for surgical prophylaxis as standardized guidelines differ globally.
## Pediatric Dosing
* **Trauma:** 15 mg/kg IV loading dose (max 1 g), followed by 2 mg/kg/hour infusion for up to 8 hours (or until bleeding is controlled).
* **Cardiovascular Surgery:** Varies significantly by site/protocol (typically 10–50 mg/kg loading doses).
* **Note:** Pediatric dosing is frequently off-label; consult specialized pediatric pharmacy resources or local hospital guidelines.
## Dose Adjustments
* **Renal Impairment:** Requires reduction in dose/frequency based on creatinine clearance (CrCl).
* CrCl 30–50 mL/min: 50% standard dose.
* CrCl <30 mL/min: 25% standard dose or avoid use.
* **Hepatic Impairment:** No standard dosage adjustment established.
## Contraindications
* Active intravascular clotting (thromboembolic disease or history of DVT/PE).
* Acquired disturbances of color vision (e.g., retinal pathology).
* Subarachnoid hemorrhage (controversial; caution advised).
* Hypersensitivity to tranexamic acid.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (particularly with rapid IV administration or high doses), visual disturbances (retinal artery occlusion).
## Key Drug Interactions
* **Thrombolytics:** Concomitant use with factor IX complex concentrates or anti-inhibitor coagulant complexes may increase risk of thrombosis.
* **Estrogens:** Combination with hormonal contraceptives may increase the risk of thrombosis.
## Monitoring
* **Clinical:** Monitor for signs of persistent bleeding and symptoms of venous/arterial thrombosis (e.g., calf pain, shortness of breath, chest pain, focal neurological deficits).
* **Renal:** Monitor renal function in patients with pre-existing impairment.
* **Vision:** Perform ophthalmological examinations if long-term treatment is initiated.
* **Neurological:** Monitor for seizures, especially at high doses or in patients predisposed to seizure activity.
## Clinical Pearls
* **Administration:** Rapid IV injection can cause hypotension; administer slowly.
* **Timing:** Mortality benefit in trauma is time-dependent; efficacy decreases significantly if administered >3 hours after injury.
* **Seizure Alert:** High doses of TXA, particularly during cardiac surgery or neuraxial administration, are pro-convulsant. Maintain strict adherence to dose limits.
* **Oral vs. IV:** Oral formulations are primarily indicated for heavy menstrual bleeding and are not interchangeable with IV forms for acute hemorrhage management.
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**Educational Disclaimer:** This information is for educational purposes only and does not constitute medical advice. Prescribing practices and institutional protocols vary. Always verify current prescribing information, package inserts, and hospital-specific guidelines before administration.
