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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 the breakdown of fibrin clots.
## Primary Indications
* **Trauma-related hemorrhage:** Management of severe bleeding (CRASH-2 protocol).
* **Postpartum hemorrhage (PPH):** Treatment of active bleeding (WOMAN trial protocol).
* **Menorrhagia:** Treatment of heavy menstrual bleeding.
* **Surgery:** Prophylaxis or treatment of bleeding in cardiac, orthopedic, or dental procedures.
* **Epistaxis:** Topical or systemic management of refractory cases.
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 1 g IV loading dose over 10 minutes, followed by a continuous infusion of 1 g over 8 hours. Administer within 3 hours of injury.
* **Menorrhagia:** 1,300 mg orally three times daily (max 3,900 mg/day) for up to 5 days during menstruation.
* **Dental/Surgical (Prophylaxis):** 10 mg/kg IV preoperatively or 15–25 mg/kg orally three times daily.
## Pediatric Dosing
* **Trauma (Off-label):** 15 mg/kg IV loading dose (max 1 g), followed by 2 mg/kg/hour infusion (max 1 g/hour) for 8 hours.
* **Routine Pediatric dosing varies widely by institution; consult local institutional guidelines (e.g., PHN protocols) before administration.**
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction or longer interval based on creatinine clearance (CrCl).
* CrCl 30–50 mL/min: 50% of the standard dose.
* CrCl <30 mL/min: 25% of the standard dose.
* **Hepatic Impairment:** No specific adjustment required, but use with caution.
## Contraindications
* Active intravascular clotting.
* History of thromboembolic disease (DVT, PE, cerebral thrombosis).
* Acquired color vision disturbances (prevents monitoring of retinal toxicity).
* Subarachnoid hemorrhage (risk of cerebral ischemia/infarction).
* Hypersensitivity to TXA.
## Adverse Effects
* **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal pain (frequent with oral use).
* **Cardiovascular:** Hypotension (if infused too rapidly), rare thromboembolic events.
* **Neurological:** Seizures (particularly with high doses or rapid IV injection), headache, dizziness.
* **Ocular:** Retinal venous/arterial occlusion or impaired color vision.
## Key Drug Interactions
* **Thrombolytics/Fibrinolytics:** Concomitant use inhibits the effect of thrombolytic therapy.
* **Estrogens/Hormonal Contraceptives:** Increased risk of thrombosis when combined with systemic administration.
* **Factor IX Complex/Anti-Inhibitor Coagulant Concentrates:** Increased risk of thrombosis.
## Monitoring
* Monitor for signs of venous or arterial thrombosis (e.g., limb swelling, chest pain, dyspnea).
* Neurological status (especially if using high doses or history of epilepsy).
* Renal function (BUN/SCr) to adjust dosing.
* Visual examinations if long-term treatment is necessary.
## Clinical Pearls
* **Rapid IV Injection Warning:** Never inject rapidly (>100 mg/min); rapid bolus administration may cause severe hypotension.
* **"Golden Hour":** Efficacy in trauma is time-dependent. Benefit is significantly reduced if administered >3 hours post-injury.
* **Topical Use:** TXA is increasingly used topically (e.g., soaked gauze for epistaxis or surgical irrigation) where systemic absorption is lower but local hemostasis is achieved.
* **Oral Absorption:** Oral bioavailability is approximately 30–50%.
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*Disclaimer: This information is for educational purposes only. Always consult the most current official prescribing information (package insert) and verify dosing against local institutional guidelines before prescribing or administering medication.*
