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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:** Adjunct in the management of severe trauma to reduce mortality (CRASH-2 protocol).
* **Hemorrhage:** Management of cyclic heavy menstrual bleeding, postpartum hemorrhage (PPH), or perioperative blood loss.
* **Dental:** Oral bleeding in patients with coagulopathies (e.g., hemophilia).
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 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.
* **Menorrhagia:** 1.3 g orally three times daily (max 4 g/day) for up to 5 days during menstruation.
* **Dental/Minor Surgery:** 10–15 mg/kg IV or 1–1.5 g orally three times daily.
## Pediatric Dosing
* **Trauma:** 15 mg/kg (max 1 g) IV loading dose over 10 minutes, followed by 2 mg/kg/hr infusion for 8 hours (or until hemostasis achieved).
* **General Hemorrhage:** 10–20 mg/kg/dose IV 2–3 times daily.
* *Note: Always verify pediatric dosing against local institutional protocols and weight-based guidelines.*
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in patients with CrCl <50 mL/min.
* CrCl 30–50 mL/min: Reduce dose by 50% or increase dosing interval.
* CrCl <30 mL/min: Use with extreme caution; avoid if possible.
* **Hepatic Impairment:** No specific dosing adjustment required.
## Contraindications
* Known hypersensitivity to tranexamic acid.
* Active thromboembolic disease (DVT, PE, cerebral thrombosis).
* History of subarachnoid hemorrhage (due to risk of cerebral edema/seizures).
* Acquired defective color vision (prevents monitoring of optic toxicity).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal cramps.
* **Serious:** Thromboembolic events (DVT, MI, stroke), seizures (particularly with rapid IV infusion or high doses), visual disturbances (retinal artery/vein occlusion), and allergic reactions.
## Key Drug Interactions
* **Thrombolytics/Factor VII:** Concomitant use increases risk of thrombosis.
* **Estrogens/Oral Contraceptives:** May increase risk of thrombosis; use with caution.
* **Prothrombin Complex Concentrates/Antithrombin:** Avoid concurrent use; may antagonize the effect of TXA or increase pro-thrombotic risk.
## Monitoring
* Monitor for signs of venous or arterial thrombosis (leg swelling, chest pain, dyspnea, focal neurologic deficits).
* Monitor hemoglobin/hematocrit and coagulation panels as clinically indicated.
* Neurologic assessment for seizure activity if high doses are employed.
## Clinical Pearls
* **Seizure Risk:** Rapid IV pushes have been associated with seizures. Always administer as a slow infusion over 10 minutes or more.
* **Administration:** Oral tablets should be swallowed whole; do not crush.
* **Local Protocols:** Dosing for PPH and trauma varies significantly by institutional protocol (e.g., WOMAN trial guidelines vs. local trauma center standards). Ensure adherence to your facility’s specific clinical pathway.
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*Disclaimer: This information is for educational purposes only and does not supersede local institutional policies or clinical judgment. Verify all doses and contraindications in current prescribing information or your local pharmacy formulary before administration.*
