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# Tranexamic acid
## Overview
Tranexamic acid is an antifibrinolytic agent that inhibits the breakdown of fibrin clots by blocking lysine binding sites on plasminogen, thereby preventing plasminogen from binding to fibrin and initiating fibrinolysis.
## Primary Indications
* Hemorrhage or risk of hemorrhage in hyperfibrinolysis conditions.
* Menorrhagia.
* Epistaxis.
* Gastrointestinal bleeding.
* Hematuria.
* Dental extractions in patients with coagulation disorders.
* Hereditary angioedema (off-label).
## Adult Dosing
Dosing varies significantly based on indication and whether administration is oral or intravenous. Consult specific institutional protocols for definitive guidance. Generally:
* **Hemorrhage/Hyperfibrinolysis (Intravenous):** 1 gram intravenously every 6 to 8 hours. Higher doses may be used in severe bleeding, but data on doses exceeding 4 grams per day is limited.
* **Menorrhagia (Oral):** 1 gram to 2 grams orally three times daily for up to 4 days during menstruation, not to exceed 4 grams daily.
* **Epistaxis, GI Bleeding, Hematuria (Oral):** 1 gram to 2 grams orally three times daily.
* **Dental Extractions (Coagulopathy):** 1 gram to 2 grams orally 3-4 times daily starting the day before surgery and continuing for 2-8 days post-operatively. Alternatively, 10-15 mg/kg orally 3-4 times daily. A mouth rinse (e.g., 5 mL swishing and spitting 4 times daily) may also be used.
## Pediatric Dosing
Limited established pediatric dosing exists. Dosing is typically extrapolated from adult data based on weight. Consult with a pediatric specialist for specific recommendations. A common extrapolated oral dose for menorrhagia is 10-25 mg/kg/dose every 6-8 hours.
## Dose Adjustments
* **Renal Impairment:** Dose reduction is required.
* Creatinine Clearance (CrCl) 50-80 mL/min: 1 gram twice daily (oral) or 1 gram every 12 hours (IV).
* CrCl 10-50 mL/min: 1 gram once daily (oral) or 1 gram every 24 hours (IV).
* CrCl <10 mL/min: 0.5 gram once daily (oral) or 0.5 gram every 24 hours (IV).
* Dose further reduced in hemodialysis or continuous renal replacement therapy.
## Contraindications
* Active intravascular clotting or thrombosis.
* Hypersensitivity to tranexamic acid.
* Acquired defective color vision (oral formulation).
## Adverse Effects
Common adverse effects include gastrointestinal disturbances (nausea, vomiting, diarrhea), dizziness, and headache. Serious adverse effects are rare but can include thromboembolic events (deep vein thrombosis, pulmonary embolism, stroke), visual disturbances, and allergic reactions.
## Key Drug Interactions
* **Hormonal contraceptives:** Increased risk of thromboembolic events.
* **Factor VIIa (recombinant):** Increased risk of thrombosis.
* **Antiplatelet agents and anticoagulants:** May theoretically antagonize the hemostatic effects of tranexamic acid, though clinical significance is debated.
## Monitoring
* Monitor for signs and symptoms of thromboembolic events (e.g., leg pain, swelling, shortness of breath, chest pain, sudden severe headache, vision changes).
* Monitor for visual changes, especially with long-term use.
* Monitor for signs of hypersensitivity reactions.
* Renal function should be monitored to guide dose adjustments.
## Clinical Pearls
* Tranexamic acid is most effective when initiated early in the bleeding episode.
* Oral administration generally requires higher doses and more frequent administration compared to intravenous.
* Consider the potential for urothelial tumors to cause hematuria; tranexamic acid may mask this.
* Long-term use (beyond 1 year) in women with menorrhagia has shown an increased incidence of ocular abnormalities; regular ophthalmic examinations are advised.
*Disclaimer: This information is intended for clinical pharmacy professionals and does not replace a thorough review of the current prescribing information or local protocols. Always verify medication details before patient administration.*
