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# Tranexamic Acid (TXA) ## Overview Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, thereby preventing the breakdown of fibrin clots. It is available in oral and intravenous (IV) formulations. ## Primary Indications * Treatment/prevention of hemorrhage in patients with hemophilia (e.g., dental extractions). * Heavy menstrual bleeding. * Trauma-associated hemorrhage (CRASH-2 protocol). * Surgical prophylaxis (e.g., orthopedic, cardiac). * Epistaxis (topical or systemic). ## Adult Dosing * **Trauma (CRASH-2):** Loading dose of 1 g IV over 10 minutes, followed by an IV infusion of 1 g over 8 hours (must be initiated within 3 hours of injury). * **Heavy Menstrual Bleeding:** 1,300 mg orally 3 times daily for up to 5 days during menstruation. * **Dental Extraction in Hemophiliacs:** 10 mg/kg IV immediately before the procedure, followed by 25 mg/kg orally 3 to 4 times daily for 2 to 8 days. * **Surgical Prophylaxis:** Varies widely by institutional protocol (typically 1 g to 2 g IV pre-operatively). ## Pediatric Dosing * **Trauma (OFF-LABEL):** 15 mg/kg (max 1 g) IV loading dose, followed by 2 mg/kg/hour infusion for 8 hours (pediatric data extrapolated; consult institutional guidelines). * **Hemophilia (Short-term prophylaxis):** 25 mg/kg orally 3 times daily. * **Note:** Always verify dosing against local pediatric weight-based protocols. ## Dose Adjustments * **Renal Impairment:** Dosage must be reduced in patients with moderate to severe renal impairment (CrCl <50 mL/min) due to risk of accumulation and potential for seizures. * CrCl 30–50 mL/min: Reduce dose/frequency by 50%. * CrCl <30 mL/min: Reduce dose by 75%. * **Hepatic Impairment:** No standard adjustment required, but use with caution. ## Contraindications * History of venous or arterial thrombosis (unless risk is outweighed by life-threatening hemorrhage). * Active intravascular clotting. * Acquired defective color vision (prevents monitoring for visual side effects). * Subarachnoid hemorrhage (risk of cerebral ischemia/infarction). * Hypersensitivity to TXA. ## Adverse Effects * **Gastrointestinal:** Nausea, vomiting, diarrhea, abdominal pain (more common with oral dosing). * **Neurological:** Seizures (especially with rapid IV injection or high-dose intraspinal administration). * **Ocular:** Visual disturbances (blurred vision, color vision changes). * **Vascular:** Thromboembolic events (DVT, PE, MI, stroke). ## Key Drug Interactions * **Thrombolytics:** Concurrent use with thrombolytic agents (e.g., alteplase) significantly reduces the efficacy of the thrombolytic. * **Estrogens/Combined Oral Contraceptives:** May increase the risk of thromboembolism when used concurrently. * **Prothrombin Complex Concentrates (PCCs)/Factor IX:** Potential increased risk of thrombosis. ## Monitoring * Renal function (CrCl). * Signs/symptoms of thromboembolism (e.g., chest pain, leg swelling, shortness of breath). * Ophthalmologic exams if undergoing long-term treatment. * In trauma or perioperative settings: Follow institutional hemorrhage protocols. ## Clinical Pearls * **Avoid Neuraxial/Intrathecal Use:** Inadvertent intrathecal administration is associated with severe seizure activity and death. * **Infusion Speed:** Rapid IV push can cause hypotension and cardiovascular collapse; always administer over at least 10 minutes. * **Topical Use:** Often used in surgery (e.g., soaked sponges) or epistaxis; verify concentration and volume according to specific surgical protocols. * **Uncertainty Note:** Specific dosing for massive transfusion protocols and surgical blood conservation varies significantly by hospital based on local standards of care and internal guidelines. *** *Disclaimer: This information is for educational purposes only. Clinical practice guidelines change. Always verify current prescribing information, institutional protocols, and patient-specific factors with verified drug databases (e.g., Lexicomp, UpToDate) and local clinical pharmacists before prescribing or administering medication.*