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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 degradation of fibrin clots. ## Primary Indications * Treatment/prevention of hemorrhage associated with excessive fibrinolysis. * Heavy menstrual bleeding. * Trauma-related hemorrhage (CRASH-2 protocol). * Cardiac surgery, orthopedic surgery, and dental procedures in patients with coagulopathies. ## Adult Dosing * **Trauma (CRASH-2):** 1 g IV loading dose over 10 minutes, followed by 1 g IV infusion over 8 hours. * **Heavy Menstrual Bleeding:** 1.3 g orally three times daily for up to 5 days during menstruation. * **Surgical/Procedural:** Typically 10–20 mg/kg IV bolus prior to or during surgery. ## Pediatric Dosing * **Trauma (Off-label/Protocol-dependent):** Commonly 10–15 mg/kg IV loading dose (max 1 g), followed by 2–5 mg/kg/hour infusion, or as defined by specific trauma center protocols (e.g., PATCH-Peds). * **Hereditary Angioedema:** 10–25 mg/kg orally two to three times daily. ## Dose Adjustments * **Renal Impairment:** Requires significant reduction in dosing frequency and total dose. * Creatinine clearance (CrCl) 30–50 mL/min: 10 mg/kg twice daily IV or 1.3 g once daily oral. * CrCl 10–30 mL/min: 10 mg/kg once daily IV or 650 mg once daily oral. * CrCl <10 mL/min: 10 mg/kg every 48 hours or 650 mg every 48 hours oral. ## Contraindications * Acquired defective color vision. * Subarachnoid hemorrhage (risk of cerebral edema and infarction). * Active intravascular clotting (thromboembolic disease). * Hypersensitivity to TXA. ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain (mainly oral use). * **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (especially with rapid IV injection or excessive dosing), visual color disturbances. ## Key Drug Interactions * **Thrombolytics:** Concurrent use may antagonize the effect of thrombolytic therapy. * **Estrogens/Hormonal Contraceptives:** May increase the risk of thrombosis when used with TXA. * **Factor IX complex/Antinhibitor coagulant complexes:** Increased risk of thrombosis. ## Monitoring * Renal function (CrCl). * Signs/symptoms of thromboembolic events (dyspnea, unilateral calf swelling, chest pain). * Ophthalmologic exams if treatment is protracted. * Neurological status (to monitor for seizures). ## Clinical Pearls * **Seizure Risk:** Avoid rapid IV push; administration should be via slow infusion to mitigate risk, particularly in patients with a history of seizures or neurosurgery. * **Timing:** Efficacy in trauma is time-dependent; clinical benefit diminishes significantly if administered more than 3 hours after injury. * **Oral vs. IV:** Bioavailability of oral TXA is approximately 30–50%. Do not use oral formulations for indications requiring rapid, high-concentration systemic control (e.g., acute trauma). *** *Disclaimer: This information is for educational purposes only. Dosing protocols can vary significantly by clinical setting and regional guidelines. Always consult your institution's specific clinical protocols and the most recent FDA-approved package insert or recognized drug compendia (e.g., Lexicomp, Micromedex) before prescribing or administering medication.*