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# Tranexamic acid
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, a key enzyme in fibrinolysis. By preventing the breakdown of fibrin clots, it helps to stabilize and preserve existing clots.
## Primary Indications
* Management of heavy menstrual bleeding (menorrhagia).
* Treatment of or prevention of bleeding in patients with hyperfibrinolysis (e.g., certain surgical procedures, trauma, hematuria).
## Adult Dosing
* **Heavy Menstrual Bleeding:** 1300 mg orally three times daily for up to 4 days during menstruation. Maximum: 3900 mg/day.
* **Bleeding due to Hyperfibrinolysis:** Typically initiated with an IV loading dose followed by a continuous infusion.
* IV Loading Dose: Often 1 gram (1000 mg) administered over 15-30 minutes.
* IV Maintenance Infusion: Typically 1 gram (1000 mg) every 6-8 hours.
* *Specific dosing for bleeding due to hyperfibrinolysis may vary significantly based on the clinical situation and local protocol. Always refer to institutional guidelines.*
## Pediatric Dosing
* **Heavy Menstrual Bleeding:** Dosing is weight-based but often mirrors adult dosing regimens in older adolescents. Oral dosing of 10-25 mg/kg/day divided into 2-4 doses (maximum 1300 mg per dose or 3900 mg/day) has been used.
* *Data for pediatric use is limited. Consult PDR or specific pediatric guidelines for detailed recommendations.*
## Dose Adjustments
* **Renal Impairment:** Dosage reduction is necessary.
* CrCl > 50 mL/min: No adjustment needed.
* CrCl 20-50 mL/min: 50% of the standard dose.
* CrCl < 20 mL/min: 25% of the standard dose.
* *Administer IV doses more frequently in severe renal impairment depending on the specific regimen.*
## Contraindications
* Active intravascular clotting or thrombosis (e.g., deep vein thrombosis, pulmonary embolism, arterial thrombosis).
* Acquired defects in color vision.
* Hypersensitivity to tranexamic acid.
* Subarachnoid hemorrhage (risk of cerebral infarction).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, dizziness.
* **Serious:** Thrombotic events (deep vein thrombosis, pulmonary embolism, arterial thrombosis), hypersensitivity reactions, allergic dermatitis, visual disturbances (particularly with long-term use or high doses).
## Key Drug Interactions
* **Hormonal contraceptives:** Increased risk of venous thromboembolism. Avoid concomitant use if possible.
* **Factor VIIa (recombinant):** Increased risk of thrombosis.
* **Antifibrinolytics (other):** Additive thrombotic risk.
* **Oral contraceptives and estrogen-containing products:** May potentiate the thrombotic effects.
## Monitoring
* Monitor for signs and symptoms of thromboembolic events (e.g., pain, swelling, redness in extremities, shortness of breath, chest pain).
* Monitor for visual changes, especially with long-term therapy.
* Monitor for nausea, vomiting, or diarrhea.
* Assess bleeding cessation and/or reduction.
## Clinical Pearls
* Tranexamic acid is generally not recommended for patients with a history of or active thromboembolic disease.
* For IV administration, do not administer as a rapid bolus injection; infuse slowly over at least 15-30 minutes.
* The risk of thrombotic complications is higher in patients using hormonal contraceptives concurrently.
* Long-term safety, particularly visual effects, should be considered for chronic indications.
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*This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information or your institution's formulary for complete details, including indications, contraindications, warnings, precautions, adverse reactions, and drug interactions before using tranexamic acid.*
