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# Tranexamic Acid (TXA)
## Overview
Tranexamic acid is an antifibrinolytic agent that acts as a competitive inhibitor of plasminogen activation. By preventing the conversion of plasminogen to plasmin, it stabilizes fibrin clots and inhibits fibrinolysis.
## Primary Indications
* Treatment/prevention of hemorrhage associated with excessive fibrinolysis.
* Trauma-related hemorrhage (CRASH-2 protocol).
* Heavy menstrual bleeding.
* Postpartum hemorrhage (WHO protocols).
* Surgical prophylaxis (cardiac, orthopedic, dental in hemophilia).
## Adult Dosing
* **Trauma:** 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.
* **Heavy Menstrual Bleeding:** 1.3 g orally three times daily for up to 5 days during menstruation.
* **Surgical Prophylaxis:** Varies by procedure; common regimens range from 10–20 mg/kg IV bolus pre-op followed by infusion or additional doses.
## Pediatric Dosing
* **Trauma:** 15 mg/kg IV loading dose (max 1 g), followed by 2 mg/kg/hour infusion for 8 hours (dependent on institution protocol).
* **Hemophilia (Dental surgery):** 25 mg/kg orally every 8 hours for 2–8 days.
* *Note:* Pediatric dosing is highly variable based on indication; always consult institutional pediatric guidelines or weight-based protocols.
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in severe renal impairment (CrCl <30 mL/min). If CrCl 15–30 mL/min, use 50% of standard maintenance dose; if CrCl <15 mL/min, use 25% of the dose.
* **Hepatic Impairment:** No specific adjustment required.
## Contraindications
* History of active thromboembolic disease (DVT, PE, cerebral thrombosis).
* Subarachnoid hemorrhage (risk of cerebral ischemia/seizure).
* Acquired defective color vision (prevents monitoring of visual adverse effects).
* Hypersensitivity to TXA.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache.
* **Serious:** Thromboembolic events (MI, DVT, PE), seizures (especially with high-dose/neuraxial administration), visual changes (retinal venous/arterial occlusion).
## Key Drug Interactions
* **Hormonal Contraceptives:** May increase risk of thrombosis when used concomitantly.
* **Thrombolytics:** Antagonistic effect; avoid concomitant use.
* **Prothrombin Complex Concentrates (PCCs)/Factor IX:** Potential increased risk of thrombotic complications.
## Monitoring
* Monitor for signs of thromboembolism (leg pain/swelling, chest pain, dyspnea).
* Assess vision if therapy is prolonged.
* Monitor renal function in patients with pre-existing impairment.
* Monitor for neurological changes (seizure risk) if high doses are administered.
## Clinical Pearls
* **Seizure Risk:** Rapid IV injection can cause hypotension and seizures; always follow the recommended infusion duration.
* **Timing:** Efficacy in trauma is highly time-dependent; clinical benefit decreases significantly if administered >3 hours post-injury.
* **Off-Label:** Frequently used for epistaxis or upper GI bleeds, though evidence varies. Always verify institutional standing orders for specific surgical indications.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical protocols vary; always verify current prescribing information, institutional guidelines, and weight-based calculations via reliable clinical databases (e.g., Lexicomp, Micromedex) or your hospital pharmacy department before administration.
