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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is a synthetic lysine analog that acts as an antifibrinolytic agent by competitively inhibiting the activation of plasminogen to plasmin, thereby preventing fibrin clot dissolution.
## Primary Indications
* **Trauma/Hemorrhage:** Management of severe traumatic hemorrhage (CRASH-2 protocol).
* **Surgery:** Reduction of blood loss in surgical procedures (e.g., orthopedic, cardiac).
* **Obstetrics:** Treatment or prophylaxis of postpartum hemorrhage.
* **Other:** Menorrhagia, epistaxis, and hereditary angioedema.
## Adult Dosing
* **Trauma:** 1 g IV 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 over 10 minutes. A second 1 g dose may be administered if bleeding continues after 30 minutes.
* **Menorrhagia:** 1.3 g PO three times daily for up to 5 days during menstruation.
* **Surgical Prophylaxis/Other:** Dosing varies widely by procedure (typically 10–100 mg/kg or fixed 1–2 g IV Bolus).
## Pediatric Dosing
* **Trauma:** 15 mg/kg (max 1 g) IV bolus, followed by 2 mg/kg/hour infusion for 8 hours (based on pediatric trauma guidelines; protocols vary by institution).
* **Other indications:** Dosing is highly variable; consult pediatric-specific tertiary references (e.g., *The Harriet Lane Handbook*) or local pediatric hematology protocols.
## Dose Adjustments
* **Renal Impairment:** Requires significant dose reduction or increased dosing intervals in patients with CrCl < 50 mL/min to prevent drug accumulation and risk of seizures.
* CrCl 30–50 mL/min: 10 mg/kg IV twice daily.
* CrCl 10–30 mL/min: 10 mg/kg daily.
* CrCl < 10 mL/min: 5 mg/kg daily.
* **Hepatic Impairment:** No formal adjustments established; clinical caution suggested.
## Contraindications
* Active thromboembolic disease (DVT, PE).
* History of venous or arterial thrombosis.
* Subarachnoid hemorrhage (theoretical risk of cerebral arterial vasospasm).
* Hypersensitivity to TXA.
* Severe renal impairment (if using PO formulations, depending on severity).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain (especially with oral therapy).
* **Serious:** Thromboembolic events, seizures (especially with rapid IV injection or high doses), visual disturbances (color vision changes), and hypersensitivity reactions.
## Key Drug Interactions
* **Thrombolytics:** Concomitant use inhibits the effect of thrombolytic therapy (e.g., tPA/alteplase).
* **Estrogens/Hormonal Contraceptives:** Increased risk for thrombosis.
* **Prothrombin Complex Concentrates (PCCs) / Factor IX:** Additive risk of thrombosis.
## Monitoring
* Monitor for signs of venous or arterial thrombosis (e.g., limb swelling, chest pain, dyspnea).
* Monitor neurological status (seizure risk) if high doses are used.
* Evaluate renal function (SCr) periodically during extended therapy.
## Clinical Pearls
* **Avoid rapid IV push:** Rapid administration is associated with hypotension and seizures; infuse over at least 10 minutes.
* **Timing:** For trauma, efficacy decreases significantly if administered > 3 hours after injury.
* **Off-label use:** Frequently used for epistaxis (topical/gauze soaked in 500 mg/5 mL) and traumatic hyphema.
* **Protocols:** Always verify doses against internal emergency department or surgical protocols, especially in pediatric settings where weight-based dosing is critical.
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*Disclaimer: This information is for educational purposes only. Always verify doses, contraindications, and compatibility with current local institutional protocols and official package inserts before prescribing or administering medication.*
