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# Tranexamic Acid ## Overview Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin. Plasmin is a key enzyme in the breakdown of fibrin clots. By inhibiting plasmin, tranexamic acid stabilizes clots and reduces bleeding. ## Primary Indications * Treatment of heavy menstrual bleeding. * Treatment of or prevention of bleeding in patients with congenital or acquired hemorrhagic diathesis (e.g., hemophilia, TTP). * Reduction of blood loss during and after surgery (e.g., cardiac, orthopedic, prostatectomy). * Management of epistaxis. ## Adult Dosing * **Heavy Menstrual Bleeding:** 1300 mg orally three times daily for up to 4 days. * **Hemorrhagic Diathesis (e.g., Hemophilia):** Dosing varies significantly based on the specific condition and intervention. Typical doses range from 1 gram (g) intravenously (IV) or orally (PO) every 8 hours. Specific protocols are essential. * **Surgical Blood Loss Reduction:** * IV: 1 g administered prior to incision, followed by 1 g every hour during surgery if needed, or 1 g to 2 g IV every 6 to 8 hours postoperatively. Some protocols use a continuous infusion of 1 g/hour. * Maximum IV dose: Generally, 4 g per day, though higher doses may be used in specific surgical contexts under strict monitoring. * **Epistaxis:** 500 mg to 1500 mg orally three times daily for 3 to 10 days. Some protocols advocate for topical application of tranexamic acid solution to nasal packing. ## Pediatric Dosing * There is limited established pediatric dosing for tranexamic acid. Dosing is often extrapolated from adult data and should be based on weight, clinical indication, and local protocols. * For heavy menstrual bleeding, doses around 10-25 mg/kg/day orally divided into 3-4 doses have been reported, with a maximum of 1300 mg per dose. ## Dose Adjustments * **Renal Impairment:** Dose reduction is necessary. * Creatinine clearance (CrCl) 50-80 mL/min: Reduce dose by 50%. * CrCl 10-50 mL/min: Reduce dose by 75%. * CrCl <10 mL/min: 500 mg once daily (oral) or every 12-24 hours (IV). * Anuric patients: 500 mg once daily. * **Hepatic Impairment:** No dose adjustment is typically required, but caution is advised. ## Contraindications * Active intravascular clotting or thrombosis. * Acquired defective color vision (for chronic use). * Hypersensitivity to tranexamic acid. * Subarachnoid hemorrhage (associated with an increased risk of cerebral edema and infarction). ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness. * **Less Common:** Allergic reactions, urticaria, hypotension, tachycardia, visual disturbances (especially with chronic use or high doses). * **Rare/Serious:** Thromboembolic events (e.g., deep vein thrombosis, pulmonary embolism, cerebral venous thrombosis), myocardial infarction, stroke. The risk appears higher in patients with underlying risk factors or when combined with other prothrombotic agents. ## Key Drug Interactions * **Hormonal contraceptives:** Increased risk of thromboembolic events. * **Factor IX complex concentrates, anti-inhibitor coagulant concentrates:** Potential increased risk of thrombosis. * **Antifibrinolytics (other):** Avoid concurrent use. * **Estrogens:** Potential increased risk of thrombosis. * **tPA (alteplase):** Antagonistic effect. ## Monitoring * **Renal function:** Essential for dose adjustment. * **Visual acuity and color vision:** For patients on long-term therapy. * **Signs and symptoms of thromboembolism:** Monitor closely, especially in patients with risk factors. * **Bleeding status:** Assess efficacy. ## Clinical Pearls * Tranexamic acid should be used with caution in patients with a history of thromboembolic disease or risk factors for thrombosis. * Initiate treatment as soon as possible when indicated for acute bleeding. * Topical application may be used for localized bleeding (e.g., dental extraction sites). * The risk of seizures may be increased with IV administration, particularly at high doses. *** *Disclaimer: This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines before administering any medication. Dosing and recommendations may vary based on patient-specific factors and local protocols.*