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# Tranexamic Acid ## Overview Tranexamic acid (TXA) is a synthetic lysine analog that acts as a potent 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 severely injured patients (within 3 hours of injury). * **Surgery:** Reduction of blood loss in orthopedic, cardiac, and obstetric surgery. * **Menorrhagia:** Treatment of heavy menstrual bleeding. * **Epistaxis/Minor Bleeding:** Nasal or oral mucosal bleeding (often topical). ## Adult Dosing * **Trauma:** 1 g IV bolus over 10 minutes, followed by 1 g IV infusion over 8 hours. * **Heavy Menstrual Bleeding:** 1.3 g PO three times daily for up to 5 days during menses. * **Surgery:** Dosing varies widely by protocol; common regimens include 10–20 mg/kg IV bolus followed by 1–10 mg/kg/hr infusion. * *Note: Always consult local institutional protocols for specific surgical dosing.* ## Pediatric Dosing * **Trauma:** 15 mg/kg (max 1 g) IV bolus over 10 minutes, followed by 2 mg/kg/hr infusion for 8 hours (or until hemostasis achieved). * **Surgery:** Typically 10–30 mg/kg dose; varies by institution. Consult pediatric-specific guidelines or local protocol. ## Dose Adjustments * **Renal Impairment:** Reduce dose in patients with CrCl < 50 mL/min. * CrCl 30–50 mL/min: Reduce dose by 50%. * CrCl 10–29 mL/min: Reduce dose by 75%. * CrCl < 10 mL/min: Reduce dose by 87.5% or avoid. * **Hepatic Impairment:** No standard adjustment required, but use caution. ## Contraindications * Active intravascular clotting (thromboembolic disease). * History of venous or arterial thrombosis. * Subarachnoid hemorrhage (controversial; expert consultation required). * Acquired defective color vision (prevents monitoring of retinal toxicity). * Hypersensitivity to tranexamic acid. ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal cramps. * **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (especially with rapid IV bolus or high doses), visual disturbances (color vision changes), and allergic reactions. ## Key Drug Interactions * **Thrombolytics/Fibrinolytics:** Concomitant use negates therapeutic effect. * **Estrogens/Oral Contraceptives:** Increased risk of thrombosis. * **Hemostatic agents (e.g., Factor IX complex):** Increased risk of thrombosis. ## Monitoring * **Safety:** Monitor for signs of thromboembolism (leg swelling, chest pain, dyspnea, focal neurologic deficits). * **Neurologic:** Monitor for seizures, particularly in patients with pre-existing epilepsy or those receiving high doses. * **Renal:** Monitor serum creatinine in patients with baseline renal impairment. ## Clinical Pearls * **Seizure Risk:** Rapid IV injection can precipitate seizures. Always infuse slowly or use a pump for maintenance doses. * **CRASH-2 Trial:** The landmark trial establishing the survival benefit of early TXA administration in adult trauma patients. * **Topical Use:** Frequently used for epistaxis or dental extractions soaked on gauze; negligible systemic absorption via this route. * **Uncertainty:** Dosing in pediatric trauma lacks universal consensus; institutional guidelines take precedence. *** *Disclaimer: This information is for educational purposes and does not replace professional clinical judgment. Always verify dosages, contraindications, and compatibility with your institution's current prescribing information or a reliable clinical decision support database.*