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# Tranexamic Acid ## Overview Tranexamic acid (TXA) is a synthetic antifibrinolytic agent. It acts as a competitive inhibitor of plasminogen activation, preventing the breakdown of fibrin clots (fibrinolysis). ## Primary Indications * **Trauma:** Prevention/treatment of hemorrhage (CRASH-2 protocol). * **Surgery:** Reduction of blood loss in cardiac, orthopedic, and obstetric surgery. * **Menorrhagia:** Treatment of cyclic heavy menstrual bleeding. * **Epistaxis/Dental:** Topical use in minor mucosal hemorrhage. * **Postpartum Hemorrhage (PPH):** Management of refractory hemorrhage (WOMAN trial protocol). ## Adult Dosing * **Trauma/PPH:** 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. * **Surgery:** Dosing varies widely by protocol (e.g., 10–30 mg/kg IV bolus). * **Menorrhagia:** 1.3 g orally three times daily for up to 5 days during menstruation. ## Pediatric Dosing * **Trauma:** 15 mg/kg IV loading dose (max 1 g), followed by 2 mg/kg/hour infusion for 8 hours (dependent on pediatric trauma protocol). * **Off-label/Surgical:** 10–20 mg/kg IV commonly used; consult institution-specific pediatric guidelines. ## Dose Adjustments * **Renal Impairment:** Requires decreased dosage or prolonged intervals due to reduced clearance. * CrCl 30–50 mL/min: 10 mg/kg IV twice daily. * CrCl 10–30 mL/min: 10 mg/kg IV once daily. * CrCl <10 mL/min: 5 mg/kg IV once daily. * **Hepatic Impairment:** No specific adjustment necessary; limited data available. ## Contraindications * Hypersensitivity to TXA. * Active intravascular clotting (thromboembolic disease). * History of venous or arterial thrombosis (unless benefit justifies risk). * Subarachnoid hemorrhage (risk of cerebral edema and infarction). * Acquired defective color vision. ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache. * **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (particularly with rapid IV injection or high doses), visual disturbances. ## Key Drug Interactions * **Thrombolytics/Fibrinolytics:** Concomitant use negates therapeutic efficacy. * **Estrogens/Oral Contraceptives:** Increased risk of thrombosis. * **Factor IX complex/Prothrombin complex concentrates:** High risk of thrombotic complications. ## Monitoring * Monitor for signs/symptoms of thromboembolism (e.g., limb swelling, chest pain, dyspnea). * Assess vision and color perception during long-term therapy. * Monitor renal function in patients with preexisting impairment. ## Clinical Pearls * **Rapid Administration Risk:** Rapid IV injection can cause hypotension or seizures; always administer slowly or via infusion. * **Intrathecal/Intraventricular Warning:** Do not administer via these routes; severe neurotoxicity, including generalized seizures and brain edema, has been reported. * **Topical Utility:** In refractory epistaxis or oral surgery, soaking gauze in injectable TXA (100 mg/mL) is a common, effective off-label application. * **Timing is Critical:** The benefits in trauma are significantly diminished if administered more than 3 hours post-injury. *** **Educational Disclaimer:** This information is for educational purposes only. Dosing, contraindications, and clinical protocols vary by institution and patient status. Always verify current prescribing information, institutional guidelines, and manufacturer labeling before administration.