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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 degradation of fibrin clots and stabilizing hemostasis.
## Primary Indications
* **Hemorrhage Management:** Trauma-associated hemorrhage, postpartum hemorrhage (PPH), and perioperative blood loss reduction.
* **Menorrhagia:** Treatment of cyclic heavy menstrual bleeding.
* **Hereditary Angioedema:** Short-term prevention of acute attacks (off-label).
* **Dental Procedures:** Hemostasis in patients with coagulopathies.
## Adult Dosing
* **Trauma (CRASH-2 protocol):** 1 g IV loading dose over 10 minutes, followed by a 1 g continuous IV infusion over 8 hours. Administer as soon as possible, ideally within 3 hours of injury.
* **Postpartum Hemorrhage (WOMAN trial):** 1 g IV over 10 minutes. If bleeding continues after 30 minutes or recurs within 24 hours, a second 1 g dose may be administered.
* **Menorrhagia:** 1,300 mg orally three times daily for up to 5 days during menstruation.
* **Perioperative/Surgical:** Dosing varies significantly by facility protocol (typically 10–30 mg/kg IV). Consult local institutional guidelines.
## Pediatric Dosing
* **Trauma/Severe Hemorrhage:** 15–20 mg/kg IV loading dose, followed by a continuous infusion of 2–10 mg/kg/hour.
* **Note:** Pediatric dosing is often institution-specific. Verify with local protocols or pediatric dosing references (e.g., Harriet Lane).
## Dose Adjustments
* **Renal Impairment:** Requires significant reduction in dosage or increased dosing intervals due to renal clearance of the drug.
* Creatinine clearance (CrCl) 30–50 mL/min: 10 mg/kg IV twice daily or 50% of standard dose.
* CrCl <30 mL/min: 5–10 mg/kg once daily.
* **Hepatic Impairment:** No standard dosage adjustment required, but use with caution.
## Contraindications
* Active intravascular clotting (thromboembolic disease).
* History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
* Acquired defective color vision (prevents monitoring of retinal changes).
* Subarachnoid hemorrhage (due to potential for cerebral edema/ischemia).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain (especially with oral formulations).
* **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (particularly with high IV doses or off-label intrathecal/epidural use), and visual disturbances.
## Key Drug Interactions
* **Thrombolytics:** Concurrent use with thrombolytic agents (e.g., alteplase) may antagonize the therapeutic effect of the thrombolytic.
* **Hormonal Contraceptives:** Potential increased risk of thrombosis if used concurrently with estrogen-containing contraceptives.
* **Factor IX complex/Antinhibitor Coagulant Concentrates:** Increased risk of thrombotic complications.
## Monitoring
* Monitor for signs of thromboembolism (chest pain, dyspnea, limb swelling/pain).
* Ophthalmologic exams for patients on long-term therapy.
* Renal function (BUN/SCr) in patients with baseline impairment.
## Clinical Pearls
* **"Time is Tissue":** In trauma settings, TXA efficacy decreases significantly if administered more than 3 hours post-injury.
* **Seizure Risk:** Avoid rapid IV bolus injections; administer over at least 10 minutes to minimize the risk of drug-induced seizures.
* **Stability:** TXA is compatible with most common IVF, but do not mix with blood products or penicillin-based infusions.
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**Educational Disclaimer:** This information is for educational purposes only. Tranexamic acid dosing can vary widely based on clinical indication and institutional protocols. Always verify current prescribing information, package inserts, and local clinical guidelines before administration.
