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# Tranexamic acid
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin. It is used to control bleeding.
## Primary Indications
* Management of life-threatening hemorrhage (e.g., trauma, postpartum hemorrhage, gastrointestinal bleeding).
* Reduction of blood loss in surgical patients (e.g., orthopedic, cardiac, gynecological surgery).
* Management of menorrhagia.
* Epistaxis.
* Hereditary angioedema prophylaxis.
## Adult Dosing
* **Life-threatening hemorrhage:**
* **Loading dose:** 1 gram IV over 10-20 minutes.
* **Maintenance infusion:** 1 gram IV every 6 hours for up to 24 hours.
* Alternative: 1 gram IV bolus followed by 1 gram every 8 hours.
* Initial dosing may vary based on local protocol and patient condition.
* **Surgical prophylaxis:**
* 1 gram IV given within the hour before incision.
* An additional 1 gram IV may be given intraoperatively or at the end of surgery.
* Followed by 1 gram IV or orally every 6-8 hours for up to 24 hours postoperatively.
* **Menorrhagia:** 1 gram (1000 mg) orally up to 3 times daily, not to exceed 4 grams daily, for up to 5 days during menstruation.
* **Hereditary Angioedema prophylaxis:** 1000 mg orally 2-3 times daily.
## Pediatric Dosing
Pediatric dosing is not well established for all indications. Dosing should be based on local protocol and individual patient factors.
* **Hemorrhage:** Dosing is extrapolated from adult data, typically 10-25 mg/kg IV infused over 10-20 minutes, followed by 10 mg/kg/hour infusion. Maximum dose not clearly defined but generally aligns with adult limits.
* **Surgical Prophylaxis:** Similar to adult recommendations, depending on patient weight and local protocol.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is necessary.
* Creatinine clearance >50 mL/min: 15 mg/kg every 8 hours.
* Creatinine clearance 10-50 mL/min: 7.5 mg/kg every 8 hours or 15 mg/kg every 12 hours.
* Creatinine clearance <10 mL/min: 7.5 mg/kg every 24 hours. Adjust based on interval dosing.
## Contraindications
* Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, arterial thrombosis).
* Acquired defect in color vision.
* Hypersensitivity to tranexamic acid.
* Subarachnoid hemorrhage (risk of cerebral edema and infarction).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thromboembolic events (stroke, myocardial infarction, deep vein thrombosis, pulmonary embolism), hypersensitivity reactions (anaphylaxis), visual disturbances, dizziness, hypotension (with rapid IV infusion).
## Key Drug Interactions
* **Hormonal contraceptives:** Increased risk of thromboembolic events. Concurrent use should be carefully evaluated.
* **Factor VIIa (recombinant):** Increased risk of thrombosis. Avoid concurrent administration.
* **Antifibrinolytics (e.g., aminocaproic acid):** Avoid combined use due to theoretical increased risk of thrombosis.
## Monitoring
* Monitor for signs and symptoms of thromboembolic events.
* Monitor for allergic reactions.
* Assess bleeding status and response to therapy.
* Renal function in patients with impaired kidney function.
* Visual acuity and color vision with prolonged therapy.
## Clinical Pearls
* The benefit of tranexamic acid in trauma may be reduced if not administered within 3 hours of injury.
* Rapid IV infusion can cause hypotension and reflex tachycardia. Administer as a slow infusion or bolus.
* Consider topical application for local bleeding control (e.g., epistaxis, dental surgery).
* Oral administration has a slower onset of action compared to IV.
* Use with caution in patients with a history of thromboembolic events.
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*This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details before making any treatment decisions.*
