Pharm
Tranexamic Acid
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Tranexamic Acid
, Lysteda, Cyklokapron, TXA
Indications
Life-Threatening
Hemorrhage
Some EMS services are initiating Tranexamic Acid in the field (esp. >45 min from Level I
Trauma
)
Subarachnoid Hemorrhage
(
Anticoagulant Reversal
)
Massive Hemorrhage
with refractory bleeding and cardiovascular collapse
Hypotension in the Dialysis Patient
Acute Gastrointestinal Hemorrhage
Acute Localized Bleeding
Menorrhagia Management
(taken orally)
Refractory
Epistaxis
(topical to nares atomized)
Control of Hemorrhage after Tonsillectomy
(gargled)
Dental procedure bleeding (topical to
Gingiva
)
Prophylaxis of bleeding
Tooth Extraction
in patients with
Hemophilia
or other
Coagulopathy
Contraindications
Not approved for pediatric
Hemorrhage
Subarachnoid Hemorrhage
Thromboembolism
(venous or arterial)
Concurrent thrombosis management
Concurrent
Seizure
activity
Concurrent factor concetrate (
Cryoprecipitate
) administration
Disseminated Intravascular Coagulation
Macroscopic
Hematuria
Color Blindness (TXA is associated with vision changes in this cohort)
Exercise
caution with those on
Oral Contraceptive
s (venous thrombosis risk)
Background
Tranexamic Acid (TXA) is a synthetic derivative of the amino acid lysine
Tranexamic Acid-like agents are found in tea
Hence the reason tea bags may be used topically to slow dental bleeding
Mechanism
Tranexamic Acid (TXA) is an antifibrinolytic that prevents plasminogen activation
TXA reversibly attaches and blocks at the plasminogen lysine binding site
Plasmin may still be formed by endogenous tPA, but the plasmin formed is inactive
Fibrin clot is therefore stabilized by preventing plasmin mediated
Fibrinolysis
Dosing
Tranexamic Acid for Life Threatening
Hemorrhage
Tranexamic Acid (TXA) concentration: 100 mg/ml in 10 ml vial
Adults
Initial: Tranexamic Acid (TXA) 1 g over 10 minutes
Maximum infusion rate 100 mg/min to prevent
Hypotension
If
Hypotension
occurs, extend infusion to 20 minutes
Next (if
Serum Creatinine
<3 g/dl)
Tranexamic Acid Infusion at 1 g (10 ml) in 250 ml NS infused at 32 ml/h over 8 hours OR
Repeat dose 1 g over 10 minutes at 8 hours after first
Hospital administration
Add 1 g TXA (10 ml) to 50 ml bag NS
Prehospital administration
EMS dilutes 10 ml TXA in 50 ml
Normal Saline
bag
Runs via 10 cc/ml tubing at 1 drip/second
Child:
Bolus: 15 mg/kg up to 1000 mg over 10 minutes
Infusion: 2 mg/kg/h for 8 hours or until bleeding stops
Safe and effective in children
Eckert (2014) J Trauma Acute Care Surg 77(6): 852-8 +PMID:25423534 [PubMed]
Dosing
Routine Uses (ambulatory or prophylactic)
Prophylaxis before
Tooth Extraction
in
Hemophilia
Immediately before surgery
Tranexamic Acid 10 mg/kg IV
Following surgery
Tranexamic Acid 10 mg/kg orally three to four times daily for 2-8 days
(2014) Tarascon Pharmacopoeia
Oral (Lysteda for
Menorrhagia
)
Take two 650 mg tabs (1.3 g) orally three times daily for the first 5 days of the cycle
More expensive than other options for
Menorrhagia
Topical (using IV form, experimental, not FDA approved)
Epistaxis
Tranexamic Acid IV form applied topically to nasal septum via inserted cotton pledgets
Zahed (2013) am j emerg med 31(9): 1389-92 [PubMed]
Dental Procedure Bleeding
Local bleeding control for patients on
Perioperative Anticoagulation
Efficacy
Life-Threatening
Hemorrhage
(SAH,
Massive Hemorrhage
,
Trauma
)
Most effective when given in first hour of severe
Hemorrhage
Unlikely to offer benefit at 3 hours or longer from
Hemorrhage
onset and may be harmful
Inexpensive ($100) when compared with other measures used in
Hemorrhage Management
References
CRASH-2
Small mortality benefit if used in first hour of refractory
Hemorrhage
and surgery delayed
NNT 67 with a 1.5% all-cause mortality reduction at 28 days (and no significant adverse effects)
(2010) Lancet 376(9734): 23-32 [PubMed]
Roberts (2011) Lancet 377(9771):1096-101 [PubMed]
Number Needed to Treat
in the most seriously bleeding patients: 7
Morrison (2013) JAMA Surg 148(3): 218-25 [PubMed]
Efficacy
Menorrhagia
More effective than
NSAID
s
Adverse Effects
Thrombosis risk (no longer considered a risk)
Initial study concern
Follow-up studies demonstrated no increased risk of thrombosis (DVT, PE)
Nausea
or
Vomiting
Diarrhea
References
(2016)
CALS
Manual, 14th ed, 1:69
Mell in Herbert (2015) EM:Rap 15(1): 1-2
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