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# Tranexamic Acid ## Overview Tranexamic acid is an antifibrinolytic agent. It competitively inhibits the activation of plasminogen to plasmin, an enzyme that breaks down fibrin clots. ## Primary Indications * Hemorrhage due to increased fibrinolysis. * Management of menorrhagia. * Shortening of heavy bleeding associated with gynecological surgery. * Prevention and treatment of hereditary angioedema. * Blunt or penetrating trauma associated with significant hemorrhage (e.g., TRAUMATIC BRAIN INJURY). ## Adult Dosing Dosing varies significantly based on indication. Local protocols should be consulted. * **Hemorrhage (general):** Often initiated with a bolus of 1 gram (g) IV, followed by an infusion of 1 g every 8 hours (h). Some protocols may use 1 g IV every 6-8h. * **Menorrhagia:** 1 g orally three times daily for up to 4 days during menstruation. * **Gynecological surgery:** 1 g orally 1-2 hours before surgery, followed by 1 g orally or IV every 6-8 hours up to 24 hours post-operatively. * **Hereditary Angioedema (prophylaxis):** 1000 mg orally two or three times daily. * **Hereditary Angioedema (acute attack):** 1000 mg orally every 8 hours. * **Trauma (e.g., TBI):** 1 g IV bolus, followed by 1 g IV infusion over 1 hour, then 1 g IV infusion over 8 hours. Not to exceed 3 g in 24 hours. Dosing within 3 hours of injury is most effective. ## Pediatric Dosing Dosing in children is less well-established and varies by indication. Consult pediatric-specific guidelines or local protocols. * **Hemorrhage:** Extrapolation from adult data suggests doses of 10-25 mg/kg IV every 6-8 hours. Maximum dose not to exceed adult dose. * **Menorrhagia:** 10-15 mg/kg orally three times daily for up to 4 days. ## Dose Adjustments * **Renal Impairment:** Dosage adjustment is required. * Creatinine Clearance (CrCl) 30-79 mL/min: Administer 50% of the usual dose every 12 hours. * CrCl < 30 mL/min: Administer 25% of the usual dose every 12-24 hours. * Anuric patients: Administer 25% of the usual dose every 24 hours. * **Hepatic Impairment:** No specific dose adjustment is typically required as the drug is not metabolized by the liver. ## Contraindications * Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, arterial thrombosis). * Acquired defects in color vision. * Hypersensitivity to tranexamic acid. ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain, dizziness, headache. * **Serious:** Thrombosis (arterial or venous), allergic reactions (including anaphylaxis), visual disturbances, seizures (especially with rapid IV administration). ## Key Drug Interactions * **Hormonal contraceptives (oral, transdermal, vaginal rings, implants, injections):** Increased risk of thrombosis. Concomitant use should be carefully considered and may warrant alternative strategies. * **Factor IX complex concentrates, anti-inhibitor coagulant concentrates:** Increased risk of thrombosis. * **Tretinoin:** May antagonize the effects of tranexamic acid. ## Monitoring * Monitor for signs and symptoms of thromboembolic events (e.g., limb pain/swelling, chest pain, shortness of breath, neurological deficits). * Monitor for visual changes. * Monitor for allergic reactions. * Assess therapeutic effectiveness (e.g., reduction in bleeding).