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# Tranexamic Acid
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, thus preventing the degradation of fibrin clots.
## Primary Indications
* Hemorrhage due to increased fibrinolysis.
* Prophylaxis and treatment of bleeding and edema in hereditary angioneurotic edema (HAE).
* Heavy menstrual bleeding.
* Epistaxis, hematuria, gastrointestinal bleeding, and bleeding following prostatic or gynecologic surgery.
* Reduction of blood loss in orthopedic surgery.
## Adult Dosing
* **Hemorrhage due to increased fibrinolysis:**
* **Initial dose:** 1 g (1000 mg) intravenously (IV) given over 10-20 minutes.
* **Maintenance dose:** 1 g (1000 mg) IV every 6-8 hours.
* **Maximum initial dose:** 25 mg/kg (11 mg/lb) or 1 g (1000 mg). Maximum daily dose generally 4-5 g (4000-5000 mg).
* **Heavy menstrual bleeding:**
* 500 mg orally twice daily, or up to 4 times daily as needed, not to exceed 3-4 g (3000-4000 mg) per day.
* **Prophylaxis of hereditary angioneurotic edema (HAE):**
* 1000-1500 mg (1-1.5 g) orally two to three times daily.
* **Reduction of blood loss in orthopedic surgery:**
* **IV:** Dosing protocols vary. Commonly, a loading dose of 10-15 mg/kg IV is given before incision, followed by infusions of 1-1.5 mg/kg/hour for the duration of surgery. Some protocols include additional IV doses 4 and 8 hours postoperatively.
* **Oral:** 1000 mg (1 g) orally 3 times daily on the day of surgery and for up to 4 days postoperatively.
* *Specific dosing often follows institutional surgical protocols.*
## Pediatric Dosing
* Limited data available for pediatric use. Dosing is typically based on adult recommendations and adjusted for weight.
* **Prophylaxis of bleeding in outpatient setting (e.g., dental extraction in patients with hemophilia):** 25 mg/kg/dose orally 3 to 4 times daily. Maximum dose: 1 g (1000 mg) per dose.
* **Hemorrhage due to increased fibrinolysis (IV):** Dosing varies, but often 10 mg/kg/dose IV up to 4 times daily. *Consult pediatric hematology/critical care for specific recommendations.*
## Dose Adjustments
* **Renal Impairment:**
* CrCl 50-80 mL/min: Reduce dose by 50%.
* CrCl 10-50 mL/min: Reduce dose by 75%.
* CrCl <10 mL/min: Give 1/4 of usual dose every 12 hours.
* **Hepatic Impairment:** No dose adjustment necessary.
## Contraindications
* Active intravascular clotting.
* Hypersensitivity to tranexamic acid.
* Acquired defective color vision.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thrombotic events (e.g., deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction), hypersensitivity reactions, visual disturbances, allergic dermatitis.
## Key Drug Interactions
* **Hormonal contraceptives (oral, transdermal, vaginal rings, implants, injections):** Increased risk of venous thromboembolism (VTE). Concurrent use should be approached with caution and a careful risk-benefit assessment.
* **Antithrombotics (e.g., heparin, warfarin, antiplatelet agents):** Theoretically, tranexamic acid may potentiate the thrombotic risk of these agents. However, it is often used concomitantly with anticoagulants in specific clinical situations under strict monitoring.
## Monitoring
* Monitor for signs and symptoms of thrombotic events.
* Monitor for gastrointestinal upset.
* Baseline and periodic visual examination (especially with prolonged therapy).
* Renal function in patients with impaired kidney function.
## Clinical Pearls
* Tranexamic acid is a lysine analogue that inhibits fibrinolysis.
* It is generally considered safe and effective for treating or preventing bleeding from hyperfibrinolysis.
* Oral formulation is effective for heavy menstrual bleeding.
* IV administration requires careful monitoring for thrombotic complications.
* Use with caution in individuals with a history of thrombotic disease or concurrent use of hormonal contraceptives.
* The efficacy and safety of tranexamic acid in certain indications (e.g., trauma, subarachnoid hemorrhage) are still debated and specific protocols should be followed.
_Please verify current prescribing information with the official drug manufacturer's labeling or a trusted pharmaceutical reference._
