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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
* Treatment and prevention of bleeding in conditions such as menorrhagia, epistaxis, gastrointestinal bleeding, and postsurgical bleeding.
* Management of hereditary angioedema.
* Off-label use for traumatic hemorrhage.
## Adult Dosing
* **Menorrhagia:** 1000-1500 mg orally three times daily for no more than 4-5 days during menstruation.
* **Bleeding (general):** 1000-1500 mg orally or intravenously every 6-8 hours.
* **Hereditary Angioedema:** Varies based on prophylactic or treatment needs. Prophylaxis typically 1000 mg orally two to three times daily. Treatment doses can be higher.
* **Traumatic Hemorrhage (per CRASH-2 trial, use based on institutional protocol):** 1 gram IV load, followed by 1 gram IV over 8 hours.
## Pediatric Dosing
Dosing in children is not well-established and should be based on clinical judgment, weight-based calculations, and institutional protocols. For menorrhagia, doses of 10-25 mg/kg/day orally, divided into three doses, have been used.
## Dose Adjustments
* **Renal Impairment:** Dose adjustment is necessary based on creatinine clearance.
* CrCl 50-80 mL/min: 50% of usual dose.
* CrCl 10-50 mL/min: 25% of usual dose.
* CrCl <10 mL/min: 12.5% of usual dose.
* In all cases, dosing interval may need to be extended.
## Contraindications
* Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, arterial thrombosis).
* Acquired defective color vision.
* Subarachnoid hemorrhage (risk of cerebral infarction and ischemia).
* Hypersensitivity to tranexamic acid.
## Adverse Effects
Common: Nausea, vomiting, diarrhea, abdominal pain.
Serious: Thromboembolic events (stroke, myocardial infarction, deep vein thrombosis, pulmonary embolism), hypersensitivity reactions, visual disturbances.
## Key Drug Interactions
* **Hormonal contraceptives:** Increased risk of thrombosis.
* **Factor VIIa (recombinant):** Case reports of thrombosis.
* **Antifibrinolytics (e.g., aminocaproic acid):** Theoretical additive risk of thrombosis.
## Monitoring
* Assess bleeding episodes and response to therapy.
* Monitor for signs and symptoms of thromboembolic events.
* Baseline and periodic visual examinations, especially with long-term therapy.
* Renal function.
## Clinical Pearls
* IV administration is preferred for acute, severe bleeding.
* Oral therapy is effective for menorrhagia and prevention of hereditary angioedema attacks.
* Discontinue therapy if thromboembolic events occur. Promptly discontinue if visual changes are noted.
* The CRASH-3 trial suggested potential benefit in head injury, but routine use is not recommended outside of clinical trials or specific protocols.
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*This information is intended for healthcare professionals. Clinicians should always consult the current prescribing information and consider individual patient factors.*
