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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 responsible for fibrinolysis, thus tranexamic acid reduces the breakdown of blood clots.
## Primary Indications
* Treatment and prevention of bleeding associated with hyperfibrinolysis (e.g., post-operative bleeding, trauma, menorrhagia, epistaxis).
* Management of hereditary angioedema (less common, off-label use).
## Adult Dosing
* **General Hemorrhage/Trauma:** Typically initiated with an intravenous (IV) bolus of 1 gram (g) over 10-20 minutes, followed by a continuous IV infusion of 1 g per hour for up to 24 hours. Dosing can be adjusted based on bleeding severity and local protocols.
* **Post-operative Bleeding (e.g., Cardiac Surgery):** Dosing varies significantly by surgical service and protocol. Common regimens include:
* IV bolus of 1 g, followed by an infusion of 1 g per hour for 4 hours.
* A loading dose of 10 mg/kg followed by an infusion of 1 mg/kg/hour.
* **Menorrhagia:** Oral: 1 g three times daily for up to 4 days during menstruation. Maximum dose: 4 g per day.
* **Epistaxis:** Oral: 1 g three times daily for up to 4 days. Topical application in spray or solution can also be used.
## Pediatric Dosing
Data for pediatric dosing is limited. Dosing should be guided by specific indications, weight, and institutional protocols.
* **Trauma (proposed):** IV: 10-20 mg/kg bolus, followed by 1 mg/kg/hour infusion. Maximum daily dose generally not to exceed adult maximums.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is necessary.
* Creatinine Clearance (CrCl) 50-80 mL/min: 50% of usual dose.
* CrCl 10-50 mL/min: 25% of usual dose.
* CrCl <10 mL/min: 12.5% of usual dose.
* Dosing interval may also need adjustment.
## Contraindications
* Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, arterial thrombosis).
* Acquired defects in color vision (unless used for life-threatening hemorrhage).
* Hypersensitivity to tranexamic acid.
* Subarachnoid hemorrhage (associated with increased risk of cerebral infarction).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, dizziness.
* **Serious:** Thromboembolic events (myocardial infarction, stroke, deep vein thrombosis, pulmonary embolism), hypersensitivity reactions, visual disturbances (especially with long-term use).
## Key Drug Interactions
* **Hormonal contraceptives (oral, patch, ring):** Increased risk of venous thromboembolism.
* **Factor VIIa (recombinant):** Increased risk of thrombotic complications. Concurrent use is generally not recommended.
* **Antifibrinolytics (e.g., aminocaproic acid):** Increased risk of thrombosis.
## Monitoring
* Assess for signs and symptoms of thromboembolic events (e.g., chest pain, shortness of breath, leg swelling, sudden severe headache, vision changes).
* Monitor renal function for dose adjustments.
* Visual acuity and color vision screening for patients on long-term therapy.
* Monitor bleeding status and transfusion requirements.
## Clinical Pearls
* Initiate promptly in trauma patients with suspected or confirmed hemorrhage.
* IV administration is preferred for acute bleeding.
* Oral formulations are effective for menorrhagia and can be used for other indications where IV access is not critical.
* Avoid concurrent use with hormonal contraceptives if possible; if unavoidable, counsel on VTE risks.
* Renal dose adjustments are crucial to prevent accumulation and toxicity.
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*Please verify the current prescribing information for specific indications, contraindications, dosages, and potential adverse effects before initiating therapy.*
