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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, and by inhibiting it, tranexamic acid promotes hemostasis. ## Primary Indications * Hemorrhagic conditions: To reduce or prevent bleeding in various settings, including menorrhagia, postpartum hemorrhage, gastrointestinal bleeding, and bleeding associated with surgery or trauma. * Hereditary angioedema: Prophylaxis or treatment of acute attacks. * Dental procedures in patients with bleeding disorders. ## Adult Dosing * **Hemorrhagic conditions (general):** 1 gram (g) orally three to four times daily. * **Menorrhagia:** 1 g to 1.5 g orally three to four times daily for up to 5 days during menstruation, *or* continuously for patients with regular cycles. * **Postpartum hemorrhage:** 1 g IV (slowly, not exceeding 100 mg/min). If bleeding continues, a second 1 g dose may be given IV. *A loading dose of 1 g may be followed by an infusion of 1 g every 8 hours, depending on local protocol.* * **Perioperative bleeding:** 500 mg to 1 g IV before surgery, followed by 1 g IV or orally every 6-8 hours. Dosing may vary significantly based on surgical procedure and local protocol. * **Hereditary angioedema (acute attack):** 1 g to 1.5 g orally three to four times daily. * **Hereditary angioedema (prophylaxis):** 1 g to 1.5 g orally two to three times daily. * **Dental procedures (patients with bleeding disorders):** 10-15 mg/kg orally every 6-8 hours, starting the day before the procedure and continuing for up to 2-4 days after. Alternatively, a mouthwash solution can be used. **Maximum oral dose:** Generally 4 g daily. **Maximum IV dose:** Varies; consult specific guidelines or local protocol. ## Pediatric Dosing Dosing in children is not well established and should be individualized based on weight and clinical indication, often using a dose of 10-25 mg/kg/dose orally or IV every 6-8 hours. Specific guidelines for certain indications (e.g., adenotonsillectomy bleeding) may exist. Always consult pediatric-specific resources. ## Dose Adjustments * **Renal impairment:** Dose reduction is necessary. * **CrCl 50-80 mL/min:** 3 g/day (oral) or 1.5 g (IV) every 12 hours. * **CrCl 10-50 mL/min:** 1.5 g/day (oral) or 750 mg (IV) every 12 hours. * **CrCl <10 mL/min:** 1.5 g every 24 hours (oral or IV). * *Note: IV dosing adjustments may differ; consult specific guidelines.* ## Contraindications * Active intravascular thrombosis or thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, cerebral thrombosis). * Severe hypersensitivity to tranexamic acid. * Acquired defective color vision (use with caution). * Subarachnoid hemorrhage (associated with increased risk of cerebral infarction and death). ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, abdominal pain. * **Dermatologic:** Rash, itching. * **Ocular:** Visual disturbances (especially with prolonged use or high doses). * **Thromboembolic:** Increased risk of venous and arterial thrombosis, pulmonary embolism, myocardial infarction, stroke. This risk is higher in patients with underlying risk factors. * **CNS:** Dizziness, headache. * **Hypersensitivity:** Anaphylaxis, angioedema (rare). ## Key Drug Interactions * **Hormonal contraceptives (oral, transdermal, vaginal rings, injections, implants, IUDs):** Increased risk of thromboembolic events. Coadministration should be carefully considered. * **Factor VIIa (recombinant):** Potential for increased thrombotic risk. * **Antifibrinolytics (e.g., aminocaproic acid):** Increased risk of thrombosis. * **Estrogens:** May potentiate the prothrombotic effects. ## Monitoring * **Clinical assessment:** Monitor for signs and symptoms of bleeding and thrombosis. * **Renal function:** Essential for dose adjustment. * **Visual function:** Baseline and periodic ophthalmologic exams recommended with long-term therapy or high doses. * **Laboratory tests:** Coagulation parameters are generally not useful for monitoring efficacy but may be considered in specific situations. ## Clinical Pearls * Tranexamic acid is generally not recommended for treating diffuse intravascular coagulation (DIC) unless the primary underlying cause has been corrected and DIC is accompanied by fibrinolysis. * Rapid IV administration can cause hypotension. Administer IV doses slowly (e.g., over 1 minute). * Oral absorption is variable; consider IV administration for acute, severe bleeding. * Patient education regarding the signs and symptoms of thrombosis is crucial. *** **Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical judgment. Always consult the current prescribing information and relevant guidelines before administering any medication. Dosing and protocols can vary based on institutional guidelines and patient-specific factors.