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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. ## Primary Indications * Treatment/prevention of hemorrhage associated with excessive fibrinolysis. * Heavy menstrual bleeding. * Trauma-related hemorrhage (CRASH-2 protocol). * Dental surgery in patients with coagulopathies. * Prophylaxis/treatment of hereditary angioedema. ## 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:** 1,300 mg PO three times daily for up to 5 days during menstruation. * **Dental Extraction (Coagulopathy):** 10 mg/kg IV prior to procedure, followed by 25 mg/kg PO TID for 2–8 days. * **Surgical Prophylaxis:** Varies by institutional protocol; typically 10–15 mg/kg IV prior to incision or 1 g IV pre-op. ## Pediatric Dosing * **Trauma/Hemorrhage:** 15 mg/kg (max 1 g) IV loading dose, followed by 2 mg/kg/hour infusion until bleeding is controlled or clinical status stabilizes. * **Hereditary Angioedema:** 25 mg/kg PO TID (max 1.5 g/dose). * *Note:* Pediatric dosing is frequently protocol-dependent; consult institutional guidelines for specific indications. ## Dose Adjustments * **Renal Impairment:** Significant accumulation occurs in renal failure. Dosage reduction or increased interval is required for CrCl <50 mL/min. * CrCl 30–50 mL/min: 50% of usual dose. * CrCl 10–30 mL/min: 25% of usual dose. * CrCl <10 mL/min: 10% of usual dose. * **Hepatic Impairment:** No specific adjustment required. ## Contraindications * Acquired defective color vision (prevents monitoring). * Active intravascular clotting or history of thrombosis/thromboembolism (unless benefit outweighs risk). * Subarachnoid hemorrhage (risk of cerebral ischemia/infarction). * Hypersensitivity to TXA. ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache. * **Serious:** Thromboembolic events (DVT, PE, MI, stroke), seizures (especially with rapid IV injection or high doses), visual disturbances (retinal artery occlusion), allergic reactions (anaphylaxis). ## Key Drug Interactions * **Hormonal Contraceptives:** Concomitant use with estrogen-containing products increases the risk of thrombosis. * **Prothrombin Complex Concentrates/rFVIIa:** Potential increased risk of thrombosis; use with extreme caution. * **Thrombolytics:** Concurrent use may negate the effects of thrombolytic therapy. ## Monitoring * Frequency of bleeding. * Renal function (BUN/SCr) in patients on chronic therapy or high doses. * Signs/symptoms of thromboembolism (unilateral limb swelling, chest pain, dyspnea). * Ophthalmologic exams if on long-term therapy. ## Clinical Pearls * **Seizure Risk:** Rapid IV administration has been associated with seizures, particularly in cardiac surgery patients. Always infuse slowly or use a pump. * **"Golden Hour":** In trauma, efficacy decreases significantly if administered more than 3 hours after injury. * **Route:** TXA is not intended for intrathecal administration; inadvertent injection can cause severe neurotoxicity and death. *** **Educational Disclaimer:** This information is for educational purposes only. Drug dosing, indications, and local protocols may vary significantly by institution and patient demographics. Always verify current prescribing information, clinical guidelines, and local hospital formulary protocols before prescribing or administering medication.