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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 and prevention of bleeding in patients with hyperfibrinolysis.
* Management of heavy menstrual bleeding.
* Management of bleeding associated with dental procedures in patients with bleeding disorders.
* Reduction of blood loss during and after surgery (e.g., cardiac, orthopedic, gynecologic).
## Adult Dosing
* **Heavy Menstrual Bleeding:** 1300 mg orally three times daily for up to 5 days during menstruation.
* **Surgical Blood Loss Reduction:**
* **Perioperative IV:** Commonly initiated with a loading dose of 1 g IV over 20-30 minutes, followed by an infusion of 1 g IV every 8 hours. Maximum daily dose is generally not to exceed 4 g. Specific protocols may vary based on surgical procedure and institutional guidelines.
* **On-table Cesarean Section:** 1 g IV after cord clamping. May repeat with 1 g IV if bleeding continues.
* **Dental Procedures (patients with bleeding disorders):** 1000-1500 mg orally 3-4 times daily, starting the day before the procedure and continuing for 2-7 days post-procedure.
* **Epistaxis (severe, refractory):** 1000-1500 mg orally three times daily.
## Pediatric Dosing
* **Heavy Menstrual Bleeding:** Dosing is less established. A common regimen is 10 mg/kg orally three times daily, not to exceed 4000 mg/day.
* **Surgical Blood Loss Reduction:** Dosing is variable and often based on weight and specific surgical protocols, but commonly ranges from 10-25 mg/kg IV, not to exceed adult doses.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is necessary.
* Creatinine clearance (CrCl) 50-80 mL/min: 2000 mg/day (IV or Oral)
* CrCl 10-50 mL/min: 1000 mg/day (IV or Oral)
* CrCl <10 mL/min: 500 mg/day (IV or Oral)
* *Note: IV dosing intervals may also be adjusted.*
* **Hepatic Impairment:** No dose adjustment is typically required.
## Contraindications
* Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, cerebral thrombosis).
* Acquired defects in color vision.
* Hypersensitivity to tranexamic acid.
* Subarachnoid hemorrhage (contraindicated due to increased risk of cerebral infarction).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, dizziness, headache, nasal congestion, rash.
* **Serious:** Thromboembolic events (stroke, myocardial infarction, deep vein thrombosis, pulmonary embolism), allergic reactions, visual disturbances.
## Key Drug Interactions
* **Hormonal contraceptives and estrogen-containing products:** Increased risk of thromboembolism.
* **Antifibrinolytics (e.g., aminocaproic acid):** Avoid concomitant use due to increased risk of thrombosis.
* **Factor VIIa (recombinant):** Concomitant use may increase the risk of thrombosis.
## Monitoring
* Renal function (for dose adjustments).
* Visual acuity and color vision if long-term therapy is required.
* Signs and symptoms of thromboembolic events.
## Clinical Pearls
* Tranexamic acid is a racemic mixture, but only the trans isomer is pharmacologically active.
* Administer IV tranexamic acid slowly to avoid hypotension.
* Oral absorption is generally good, but IV administration bypasses first-pass metabolism and is preferred for rapid onset or severe bleeding.
* Long-term safety data in children is limited.
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*Disclaimer: This information is intended for healthcare professionals. Prescribers should consult the most current official prescribing information and local protocols for complete details. Always verify drug information before use.*
