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# Tranexamic Acid ## Overview Tranexamic acid (TXA) is a synthetic lysine analog that acts as an antifibrinolytic agent. It competitively inhibits the activation of plasminogen to plasmin, thereby preventing the breakdown of fibrin clots. ## Primary Indications * **Trauma:** Management of hemorrhage in patients with significant traumatic injury (CRASH-2 protocol). * **Surgery:** Reduction of blood loss in orthopedic, cardiac, and dental procedures. * **Obstetrics:** Management of primary postpartum hemorrhage (PPH). * **Menorrhagia:** Treatment of cyclic heavy menstrual bleeding. * **Hereditary Angioedema:** Prophylaxis of acute attacks. ## Adult Dosing * **Trauma/Acute Hemorrhage:** 1 g IV bolus over 10 minutes, followed by 1 g IV infusion over 8 hours. Administer as soon as possible, ideally within 3 hours of injury. * **Postpartum Hemorrhage:** 1 g IV bolus over 10 minutes. A second 1 g dose may be given if bleeding persists after 30 minutes or recurs within 24 hours. * **Menorrhagia:** 1.3 g orally three times daily for up to 5 days during menstruation. ## Pediatric Dosing * **Trauma (Off-label):** 15 mg/kg (max 1 g) IV bolus, followed by 2 mg/kg/hour infusion for 8 hours. * *Note: Always verify local institutional protocols as pediatric dosing in trauma remains a subject of ongoing clinical debate.* ## Dose Adjustments * **Renal Impairment:** Requires dose reduction in patients with CrCl < 50 mL/min. * CrCl 30–50 mL/min: 1 g IV followed by 500 mg infusion over 8 hours. * CrCl 15–30 mL/min: 1 g IV followed by 250 mg infusion over 8 hours. * CrCl < 15 mL/min: 500 mg IV followed by 125 mg infusion over 8 hours. * **Hepatic Impairment:** No standard dosage adjustment required. ## Contraindications * **Active Thromboembolic Disease:** History of VTE, PE, or ischemic stroke. * **Subarachnoid Hemorrhage:** Risk of cerebral vasospasm. * **Color Vision Defect:** Known acquired defective color vision (prevents monitoring for retinal toxicity). ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain. * **Serious:** Thromboembolic events (PE, DVT, MI, stroke), seizures (particularly with rapid IV administration or high doses), visual disturbances (retinal artery/vein occlusion). ## Key Drug Interactions * **Factor IX Complex/Prothrombin Complex Concentrates:** Theoretical increased risk of thrombosis—avoid concomitant use. * **Hormonal Contraceptives:** May increase the risk of thrombosis if used concurrently with antifibrinolytics. ## Monitoring * **Clinical:** Observe for signs of thromboembolism (calf pain, chest pain, dyspnea). * **Neurological:** Monitor for seizures (especially in patients with renal impairment). * **Ophthalmological:** Baseline and periodic eye exams if long-term therapy is required. ## Clinical Pearls * **Administration:** Rapid IV bolus injection can cause hypotension; always infuse over at least 10 minutes. * **Stability:** Once diluted for IV infusion, the solution is stable at room temperature but should be used within 24 hours. * **CRASH-2 Protocol:** The greatest mortality benefit is observed when administered within 1 hour of injury; benefit diminishes significantly after 3 hours. *** **Educational Disclaimer:** This information is for educational purposes only. Clinical practice protocols and dosage guidelines are subject to change. Always verify current prescribing information, institutional guidelines, and drug compatibility via official resources (e.g., package inserts, Lexicomp, or UpToDate) before administration.