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# Tranexamic acid
## Overview
Tranexamic acid is an antifibrinolytic agent that inhibits the breakdown of fibrin clots by reversibly binding to plasminogen and blocking its interaction with fibrin.
## Primary Indications
* Treatment and prevention of bleeding in various medical and surgical settings, including:
* Heavy menstrual bleeding (menorrhagia)
* Hemorrhagic complications of thrombolytic therapy
* Prophylaxis against bleeding in patients undergoing oral surgery with deficiencies in hemostasis
* Management of epistaxis, hematuria, and gastrointestinal bleeding
* Trauma-induced coagulopathy (off-label in some settings)
* Hereditary angioedema (off-label)
## Adult Dosing
* **Menorrhagia:** 1000-1500 mg orally three times daily for up to 4 days during menstruation.
* **Surgical bleeding prophylaxis (e.g., oral surgery):** 1000-1500 mg orally 1-3 hours before surgery, followed by 1000 mg orally three times daily for 3-4 days.
* **Trauma:** 1 gram IV over 10 minutes, followed by 1 gram IV infusion over 1 hour if bleeding continues or recurs within 8 hours. May be repeated every 8 hours. Specific protocols may vary.
* **Hereditary Angioedema (HAE) prophylaxis:** 1000 mg orally two to three times daily.
* **Other bleeding:** Dosing varies significantly based on indication and severity. Intravenous doses typically range from 500 mg to 1000 mg every 8 hours. Maximum IV dose generally not to exceed 4-6 grams per day.
## Pediatric Dosing
* **Menorrhagia:** Dosing is not well established. Some sources suggest 17 mg/kg orally three times daily, maximum 1000 mg per dose, for up to 4 days.
* **Other indications:** Pediatric dosing is highly variable and often based on adult extrapolated data or specific protocols. Consultation with a pediatric hematologist or critical care specialist is recommended.
## Dose Adjustments
* **Renal Impairment:** Dose adjustment is necessary based on creatinine clearance (CrCl).
* CrCl 50-80 mL/min: 1000 mg orally twice daily or 500 mg IV every 12 hours.
* CrCl 10-50 mL/min: 500 mg orally twice daily or 500 mg IV every 12-24 hours.
* CrCl <10 mL/min: 500 mg orally once daily or 500 mg IV every 24-48 hours.
* **Hepatic Impairment:** No dose adjustment is typically required as the drug is not extensively metabolized by the liver.
## Contraindications
* Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, cerebral thrombosis).
* Acquired defects in color vision.
* Hypersensitivity to tranexamic acid.
* Subarachnoid hemorrhage (use is controversial and generally not recommended due to potential for cerebral edema and infarction).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, dizziness.
* **Serious:** Thrombosis (arterial and venous), allergic reactions, hypersensitivity.
* **Ophthalmic:** Visual disturbances, color vision impairment with prolonged use.
## Key Drug Interactions
* **Hormonal contraceptives:** Increased risk of thrombosis when used concurrently with tranexamic acid.
* **Factor VIIa (recombinant):** Concurrent use may increase the risk of thrombotic complications.
* **Antihypertensives:** No significant interactions, but use with caution in patients with pre-existing thrombotic risk factors.
## Monitoring
* Baseline and periodic ophthalmologic examinations are recommended with prolonged treatment.
* Monitor for signs and symptoms of thromboembolic events.
* Assess for therapeutic efficacy (e.g., reduction in bleeding).
## Clinical Pearls
* Tranexamic acid is generally considered safe and effective for short-term use.
* Intravenous administration should be performed slowly to minimize hypotension.
* The use in subarachnoid hemorrhage is controversial and should be approached with extreme caution, if at all, due to potential risks.
* It is a lysine analog and competes with lysine for binding sites on plasminogen.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the current prescribing information and relevant clinical guidelines for definitive dosing and management strategies, as protocols and recommendations can change.
