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# Tranexamic acid
## Overview
Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin, thereby preventing fibrinolysis.
## Primary Indications
* Treatment and prevention of bleeding in patients with hyperfibrinolysis.
* Management of heavy menstrual bleeding.
* Reduction of blood loss during and after surgery.
* Hemorrhagic stroke.
## Adult Dosing
* **General bleeding (hyperfibrinolysis):** 1 g IV every 6-8 hours. Doses may be higher in severe cases or specific surgical procedures per institutional protocol.
* **Heavy menstrual bleeding:**
* Oral: 1300 mg three times daily for up to 4 days during menstruation.
* IV: 1 g IV every 6-8 hours may be used to rapidly control bleeding in acute/severe situations.
* **Surgical bleeding:**
* IV loading dose: 10-15 mg/kg IV over 15-30 minutes immediately before incision.
* IV infusion: 1-2 mg/kg/hour for duration of surgery.
* Some surgical protocols utilize higher doses or different regimens; consult institutional guidelines.
* **Hemorrhagic stroke:** Often initiated with 1 g IV every 6-8 hours; duration varies based on clinical response and risk of rebleeding.
## Pediatric Dosing
Limited data available. Dosing is typically based on adult recommendations and adjusted by weight. Consult specialized pediatric resources or institutional protocols. For bleeding in children, doses of 10-25 mg/kg/dose IV every 6-8 hours have been used.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is necessary to avoid accumulation and toxicity.
* CrCl 50-80 mL/min: 15 mg/kg every 12 hours.
* CrCl 10-50 mL/min: 15 mg/kg every 24 hours.
* CrCl <10 mL/min: 15 mg/kg every 48 hours.
* A strict schedule based on GFR is recommended by some sources.
* **Hepatic Impairment:** No dose adjustment needed; however, monitor for adverse effects.
## Contraindications
* Active intravascular clotting or thrombosis.
* Acquired defects in color vision.
* Hypersensitivity to tranexamic acid.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, dizziness.
* **Serious:** Thrombotic events (deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke), allergic reactions, visual disturbances, seizures (especially with rapid IV administration).
## Key Drug Interactions
* **Hormonal contraceptives (oral, transdermal, vaginal):** Increased risk of venous thromboembolism. Concurrent use generally discouraged, especially with oral tranexamic acid for heavy menstrual bleeding.
* **Factor VIIa (recombinant):** Potential for severe thrombotic and/or thrombotic events.
* **Antifibrinolytics (e.g., aminocaproic acid):** Avoid concurrent use due to increased thrombotic risk.
## Monitoring
* **Renal function:** Essential for dose adjustment and preventing toxicity.
* **Visual acuity and color vision:** If prolonged therapy is anticipated or if visual symptoms occur.
* **Signs and symptoms of thrombosis:** (e.g., leg pain/swelling, chest pain, shortness of breath, neurological deficits).
* **Bleeding status:** Clinical assessment of hemostasis.
## Clinical Pearls
* Tranexamic acid is a lysine analogue that competitively inhibits plasminogen activation.
* IV administration should be slow to reduce the risk of hypotension and seizures. Rapid IV bolus is associated with increased seizure risk.
* Therapeutic benefit is usually observed within 24 hours of initiation.
* Use with caution in patients with a history of thromboembolic disease. The risk/benefit must be carefully weighed.
* Do not use in patients with definite indications for anticoagulation.
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*Disclaimer: This information is intended for clinical use by healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for definitive patient management and to verify all dosing and safety details before administration.*
