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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. It is available in oral and intravenous (IV) formulations.
## Primary Indications
* **Hemorrhage Management:** Trauma-related hemorrhage, postpartum hemorrhage (PPH), and surgical blood loss.
* **Oral/Dental:** Short-term management of cyclic heavy menstrual bleeding and prevention of bleeding in patients with hemophilia undergoing dental procedures.
* **Off-label/Protocol-dependent:** Epistaxis, gastrointestinal bleeding, and hemoptysis.
## Adult Dosing
* **Trauma/Acute Hemorrhage:** 1 g IV bolus over 10 minutes, followed by 1 g IV infusion over 8 hours. Administer as soon as possible (ideally within 3 hours of injury).
* **Postpartum Hemorrhage:** 1 g IV bolus over 10 minutes; a second 1 g dose may be administered if bleeding continues after 30 minutes.
* **Heavy Menstrual Bleeding:** 1,300 mg orally three times daily for up to 5 days during menstruation.
* **Dental (Hemophiliacs):** 25 mg/kg orally three times daily starting 1 day before procedure and continuing for 2–8 days post-op.
## Pediatric Dosing
* **Trauma (CRASH-2/STOP-AHT protocols):** 15 mg/kg (max 1 g) IV bolus, followed by 2 mg/kg/hour (max 1 g/hour) for up to 8 hours.
* **General Hemorrhage:** Dosing is often derived from institutional trauma guidelines; consultation with pediatric hematology or pharmacy is recommended.
## Dose Adjustments
* **Renal Impairment:** Dosage reduction is required for oral and IV administration in patients with CrCl <50 mL/min.
* CrCl 30–50 mL/min: 50% of the standard dose.
* CrCl <30 mL/min: 25% of the standard dose.
* **Hepatic Impairment:** No formal dose adjustment required, but use with caution.
## Contraindications
* Hypersensitivity to tranexamic acid.
* Active intravascular clotting (thromboembolic disease).
* History of intracranial bleeding.
* Acquired defective color vision (prevents monitoring of retinal toxicity).
* Subarachnoid hemorrhage (theoretical risk of cerebral infarction).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, and fatigue.
* **Serious:** Thromboembolic events (DVT, PE, MI, stroke), ocular changes (retinal vein occlusion/color vision changes), and seizures (primarily with rapid IV infusion or excessive dosing).
## Key Drug Interactions
* **Hormonal Contraceptives:** Concomitant use with estrogens may increase the risk of thrombosis.
* **Thrombolytics:** Concurrent use with thrombolytic agents (e.g., alteplase) may antagonize the therapeutic effect.
* **Prothrombin Complex Concentrates (PCCs):** Increased risk of thrombosis when used with Factor IX complex or anti-inhibitor coagulant concentrates.
## Monitoring
* **Clinical:** Monitor for signs of thromboembolism (leg swelling, chest pain, dyspnea).
* **Ophthalmologic:** Regular eye exams if long-term treatment is initiated.
* **Renal:** Monitor CrCl to determine appropriate dose adjustments.
## Clinical Pearls
* **Administration:** Never administer IV bolus too rapidly; rapid injection can cause hypotension or seizures.
* **Pre-hospital:** In trauma, TXA is most effective when administered within the "golden hour." Survival benefit decreases significantly after 3 hours post-injury.
* **Local Protocols:** Significant variation exists regarding dosing in non-trauma settings (e.g., ENT or surgical prophylaxis). Always verify against local hospital order sets.
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*Disclaimer: This information is for educational purposes only. Dosing, contraindications, and clinical protocols may vary by institution and patient-specific factors. Always verify prescribing information via current drug monographs or institutional clinical pharmacy resources before administration.*
