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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, thereby preventing the breakdown of fibrin clots. It is available as oral tablets and intravenous (IV) solution.
## Primary Indications
* **Trauma:** Adjunct in management of severe hemorrhage (within 3 hours of injury).
* **Surgery:** Reduction of blood loss in orthopedic, cardiac, and obstetric surgery.
* **Menorrhagia:** Treatment of heavy menstrual bleeding.
* **Epistaxis/Post-op bleeding:** Topical or systemic use for stabilization of clot.
## Adult Dosing
* **Trauma (CRASH-2 protocol):** 1 g IV loading dose over 10 minutes, followed by a continuous infusion of 1 g over 8 hours.
* **Heavy Menstrual Bleeding:** 1,300 mg orally three times daily (max 3,900 mg/day) for up to 5 days during menstruation.
* **Surgery:** Varies widely by institutional protocol. Common ranges include 10–30 mg/kg IV bolus, sometimes followed by an infusion.
## Pediatric Dosing
* **Trauma:** 15 mg/kg IV loading dose (max 1 g), followed by 2 mg/kg/hour infusion for 8 hours (or until hemorrhage stops).
* **Off-label/Surgical:** 10–20 mg/kg IV is commonly utilized, but dosing must be guided by institutional surgical/hematology protocols.
## Dose Adjustments
* **Renal Impairment:** Requires dose reduction in severe renal impairment (CrCl < 30 mL/min).
* *CrCl 15–30 mL/min:* 1 g every 12–24 hours (for trauma).
* *CrCl < 15 mL/min:* 1 g every 24–48 hours.
* **Hepatic Impairment:** No specific adjustments defined, but use caution.
## Contraindications
* Subarachnoid hemorrhage (risk of cerebral ischemia/infarction).
* Active intravascular clotting (thromboembolic disease).
* Acquired defective color vision.
* Hypersensitivity to TXA.
## Adverse Effects
* **Common:** GI disturbances (nausea, vomiting, diarrhea), headache, sinus/nasal symptoms.
* **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (especially with high IV doses or neuraxial administration), and visual disturbances (e.g., retinal artery occlusion).
## Key Drug Interactions
* **Thrombolytics:** Concurrent use with thrombolytics may negate the therapeutic effect of both.
* **Estrogens/Combined Oral Contraceptives:** Potential increased risk of venous thromboembolism (VTE).
* **Procoagulants:** Factor IX complex or other procoagulants may increase risk of thrombosis.
## Monitoring
* Baseline and periodic ophthalmologic examinations (for long-term therapy).
* Monitor for signs of thromboembolism (sudden dyspnea, calf pain, focal neurological deficits).
* Renal function (CrCl).
* Neurological status, specifically when high doses are administered.
## Clinical Pearls
* **Neurological Risk:** Inadvertent intrathecal administration or high IV doses carry a risk of severe neurotoxicity and seizures. NEVER administer via the spinal route.
* **Timing:** For trauma, TXA efficacy significantly decreases if administered >3 hours post-injury.
* **Stability:** Once diluted in IV fluids (e.g., NS or D5W), the solution is generally stable for 24 hours at room temperature.
* **Topical Use:** Frequently used topically in surgical fields or via gauze for epistaxis; ensure the formulation used is appropriate for the intended route (some sterile IV vials are used topically, but check hospital formulary).
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*Disclaimer: This information is for educational purposes only. Dosing protocols and indications may vary significantly by institution and clinical context. Always consult institutional guidelines and the most current FDA-approved prescribing information before administering any medication.*
