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# Tranexamic acid
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin. Plasmin degrades fibrin, which is essential for clot stability.
## Primary Indications
* Treatment of severe bleeding, particularly in patients with hyperfibrinolysis.
* Reduction of blood loss in surgical procedures.
* Management of heavy menstrual bleeding.
* Hereditary angioedema (prophylaxis and acute treatment).
## Adult Dosing
* **Severe bleeding:** Typically 1 gram (g) intravenously (IV) every 6-8 hours. Dosing can be adjusted based on clinical response and local protocol. Bolus dose often followed by an infusion.
* **Surgical procedures:** Varying protocols exist, often starting with 1 g IV before incision, followed by 1 g every hour during surgery, and potentially continued post-operatively. Specific doses depend on the procedure and local guidelines.
* **Heavy menstrual bleeding:** Oral: 1 g to 1.5 g three times daily for up to 4-5 days during menstruation.
* **Hereditary angioedema (acute):** Oral: 1 g to 1.5 g three times daily.
* **Hereditary angioedema (prophylaxis):** Oral: 1 g to 1.5 g two to three times daily.
## Pediatric Dosing
* **Bleeding:** Dosing is not well-established and should be individualized based on weight and clinical indication. A common starting point may be 10 mg/kg IV every 8 hours, not to exceed adult doses.
* **Heavy menstrual bleeding:** Oral: 15 mg/kg/day divided into three doses, not to exceed the adult dose of 4 g/day.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is recommended.
* Creatinine clearance (CrCl) 50-80 mL/min: typically 10 mg/kg or ~50% of the usual dose.
* CrCl 30-50 mL/min: typically 5 mg/kg or ~25% of the usual dose.
* CrCl 10-30 mL/min: typically 5 mg/kg every other day or ~12.5% of the usual dose frequency.
* CrCl <10 mL/min: typically 5 mg/kg every two days.
* *Note: Specific dosing guidelines and intervals vary significantly; consult institutional guidelines or renal dosing calculators.*
## Contraindications
* Active intravascular clotting (e.g., deep vein thrombosis, pulmonary embolism, arterial thrombosis).
* Acquired defective color vision.
* Hypersensitivity to tranexamic acid.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thrombotic events (e.g., stroke, myocardial infarction, deep vein thrombosis, pulmonary embolism), hypersensitivity reactions, visual disturbances (especially with prolonged high-dose therapy).
## Key Drug Interactions
* **Hormonal contraceptives (including intrauterine devices):** Increased risk of thrombosis. Caution and consideration of alternative agents may be warranted.
* **Antifibrinolytics (e.g., aminocaproic acid):** Avoid concomitant use due to increased thrombotic risk.
* **Factor VIIa (recombinant):** Concomitant use may increase thrombotic risk.
## Monitoring
* Monitor for signs and symptoms of thromboembolic events (e.g., chest pain, shortness of breath, leg swelling, new-onset neurological deficits).
* Monitor for visual changes, especially with long-term use.
* Monitor renal function for appropriate dose adjustment.
* For menstrual bleeding, monitor menstrual flow reduction.
## Clinical Pearls
* Rapid IV infusion can cause hypotension. Administer IV doses slowly over at least 1 minute.
* The highest risk of thrombosis is in patients with underlying risk factors.
* Oral administration is effective for heavy menstrual bleeding and hereditary angioedema prophylaxis/treatment.
* Use with caution in patients with a history of thrombotic disease.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before initiating treatment.*
