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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 in the breakdown of fibrin clots. ## Primary Indications * Treatment of heavy menstrual bleeding. * Reduction of blood loss associated with surgical procedures (e.g., orthopedic, cardiac, cesarean section). * Management of epistaxis. * Treatment of hereditary angioedema (prophylaxis and acute exacerbations). ## Adult Dosing * **Heavy Menstrual Bleeding:** 1300 mg orally three times daily for a maximum of 4 days. * **Surgical Procedures:** * **Orthopedic/Cardiac/Cesarean Section:** Typically 1 gram IV given before incision, followed by 1 gram IV every 8 hours for up to 24 hours. Dosing may vary based on surgical protocol or institutional guidelines. * **Other Surgical Blood Loss:** Generally, 1 gram IV may be administered, with subsequent doses of 1 gram IV every 8 hours as needed, not to exceed 4 grams per day. Consult specific protocols. * **Epistaxis:** 1-1.5 grams orally three times daily for 3-4 days. Topical application of solution may also be used. * **Hereditary Angioedema (HAE):** * **Prophylaxis:** 1000-1500 mg orally two to three times daily. * **Acute Exacerbations:** 1500 mg orally three times daily. Dosing may vary based on HAE severity and patient response. ## Pediatric Dosing Limited data for pediatric use. Dosing is generally weight-based and extrapolated from adult data or determined by institutional protocols. * **Surgical Procedures:** Investigational use at 10-25 mg/kg IV every 8 hours. ## Dose Adjustments No dose adjustment is typically required in renal impairment based on standard guidelines. However, some sources suggest a dose reduction in severe renal impairment (creatinine clearance < 30 mL/min); consult specific renal dosing guidelines. Dose adjustment may be considered in hepatic impairment, but is not usually necessary. ## Contraindications * Active intravascular thrombosis or thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, cerebral thrombosis). * Acquired defects in color vision. * Hypersensitivity to tranexamic acid. * Subarachnoid hemorrhage (may increase risk of cerebral infarction). ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, dizziness. * **Serious:** Thrombotic events (including venous and arterial thrombosis, pulmonary embolism, myocardial infarction, cerebral infarction), hypersensitivity reactions, visual disturbances, seizures (particularly with rapid IV administration or high doses). ## Key Drug Interactions * **Hormonal contraceptives:** Concurrent use may increase the risk of thrombosis. * **Antithrombotics (e.g., heparin, warfarin, aspirin):** Theoretical risk of antagonizing the effects of antithrombotics, but often used concurrently under careful monitoring. * **Factor VIIa concentrates:** Increased risk of thrombosis. * **Systemic estrogens:** Increased risk of thrombosis. ## Monitoring * Signs and symptoms of thromboembolic events. * Visual disturbances. * Renal function (for dose adjustments if severe impairment is present). * Bleeding and clotting parameters, especially when used with antithrombotics. ## Clinical Pearls * Tranexamic acid is a racemic mixture of cis- and trans-isomers; only the trans-isomer is antifibrinolytic. * Rapid IV infusion can increase the risk of hypotension and seizures. Administer IV doses slowly over at least 10-15 minutes, or as a continuous infusion. * The oral formulation has delayed absorption and lower bioavailability compared to IV. **Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and institutional guidelines for complete details and to ensure patient safety.