II. Indications

  1. Life-Threatening Hemorrhage
    1. Some EMS services are initiating Tranexamic Acid in the field (esp. >45 min from Level I Trauma)
    2. Subarachnoid Hemorrhage (Anticoagulant Reversal)
    3. Massive Hemorrhage with refractory bleeding and cardiovascular collapse
      1. Hypotension in the Dialysis Patient
      2. Acute Gastrointestinal Hemorrhage
  2. Prophylaxis of bleeding
    1. Tooth Extraction in patients with Hemophilia or other coagulopathy
  3. Ambulatory care (oral or topical)
    1. Menorrhagia (taken orally)
    2. Refractory Epistaxis (experimental, topical to nares)
    3. Dental procedure bleeding (experimental, topical to Gingiva)

III. Contraindications

  1. Not approved for pediatric Hemorrhage
  2. Subarachnoid Hemorrhage
  3. Concurrent thrombosis management
  4. Concurrent Seizure activity
  5. Concurrent factor concetrate (Cryoprecipitate) administration

IV. Background

  1. Tranexamic Acid is found in tea
    1. Hence the reason tea bags may be used topically to slow dental bleeding

V. Mechanism

  1. Tranexamic Acid (TXA) is an antifibrinolytic that prevents plasminogen activation
  2. TXA attaches at the plasminogen lysine binding site
  3. Plasmin may still be formed by endogenous tPA, but the plasmin formed is inactive
  4. Fibrin clot is therefore stabilized by preventing plasmin mediated Fibrinolysis

VI. Dosing: Life Threatening Hemorrhage

  1. Tranexamic Acid (100 mg/ml in 10 ml vial)
    1. Initial: 1 g over 10 minutes
      1. Maximum infusion rate 100 mg/min to prevent Hypotension
      2. If Hypotension occurs, extend infusion to 20 minutes
    2. Next (if Serum Creatinine <3 g/dl)
      1. Infusion at 1 g (10 ml) in 250 ml NS infused at 32 ml/h over 8 hours OR
      2. Repeat dose 1 g over 10 minutes at 8 hours after first
    3. Hospital administration
      1. Add 1 g TXA (10 ml) to 50 ml bag NS
    4. Prehospital administration
      1. EMS dilutes 10 ml TXA in 50 ml Normal Saline bag
      2. Runs via 10 cc/ml tubing at 1 drip/second

VII. Dosing: Routine Uses (ambulatory or prophylactic)

  1. Prophylaxis before Tooth Extraction in Hemophilia
    1. Immediately before surgery
      1. Tranexamic Acid 10 mg/kg IV
    2. Following surgery
      1. Tranexamic Acid 10 mg/kg orally three to four times daily for 2-8 days
      2. (2014) Tarascon Pharmacopoeia
  2. Oral (Lysteda for Menorrhagia)
    1. Take two 650 mg tabs orally three times daily for the first 5 days of the cycle
    2. More expensive than other options for Menorrhagia
  3. Topical (using IV form, experimental, not FDA approved)
    1. Epistaxis
      1. Tranexamic Acid IV form applied topically to nasal septum via inserted cotton pledgets
      2. Zahed (2013) am j emerg med 31(9): 1389-92 [PubMed]
    2. Dental Procedure Bleeding
      1. Local bleeding control for patients on Perioperative Anticoagulation

VIII. Efficacy: Life-Threatening Hemorrhage (SAH, Massive Hemorrhage, Trauma)

  1. Most effective when given in first hour of severe Hemorrhage
    1. Unlikely to offer benefit at 3 hours or longer from Hemorrhage onset and may be harmful
    2. Inexpensive ($100) when compared with other measures used in Hemorrhage Management
  2. References
    1. CRASH-2
      1. Small mortality benefit if used in first hour of refractory Hemorrhage and surgery delayed
      2. NNT 67 with a 1.5% all-cause mortality reduction at 28 days (and no significant adverse effects)
      3. (2010) Lancet 376(9734): 23-32 [PubMed]
      4. Roberts (2011) Lancet 377(9771):1096-101 [PubMed]
    2. Number Needed to Treat in the most seriously bleeding patients: 7
      1. Morrison (2013) JAMA Surg 148(3): 218-25 [PubMed]

IX. Efficacy: Menorrhagia

  1. More effective than NSAIDs

X. Adverse Effects

  1. Thrombosis risk (no longer considered a risk)
    1. Initial study concern
    2. Follow-up studies demonstrated no increased risk of thrombosis (DVT, PE)
  2. Nausea or Vomiting
  3. Diarrhea

XI. References

  1. (2016) CALS Manual, 14th ed, 1:69
  2. Mell in Herbert (2015) EM:Rap 15(1): 1-2

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Cost: Medications

tranexamic acid (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
TRANEXAMIC ACID 650 MG TABLET Generic $2.09 each

Ontology: Tranexamic Acid (C0040613)

Definition (NCI) A synthetic derivative of the amino acid lysine with antifibrinolytic activity. With strong affinity for the five lysine-binding sites of plasminogen, tranexamic acid competitively inhibits the activation of plasminogen to plasmin, resulting in inhibition of fibrinolysis; at higher concentrations, this agent noncompetitively inhibits plasmin. This agent has a longer half-life, is approximately ten times more potent, and is less toxic than aminocaproic acid, which possesses similar mechanisms of action.
Definition (MSH) Antifibrinolytic hemostatic used in severe hemorrhage.
Definition (PDQ) A synthetic derivative of the amino acid lysine with antifibrinolytic activity. With strong affinity for the five lysine-binding sites of plasminogen, transexamic acid competitively inhibits the activation of plasminogen to plasmin, resulting in inhibition of fibrinolysis; at higher concentrations, this agent noncompetitively inhibits plasmin. This agent has a longer half-life, is approximately ten times more potent, and is less toxic than aminocaproic acid, which possesses similar mechanisms of action. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=453549&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=453549&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C47765" NCI Thesaurus)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D014148
SnomedCT 109006003, 386960009
English AMCA, AMCHA, t-AMCHA, Tranexamic Acid, trans-4-(Aminomethyl)cyclohexanecarboxylic Acid, Cyclohexanecarboxylic acid, 4-(aminomethyl)-, trans-, Cyclohexanecarboxylic Acid, 4-(aminomethyl)-, trans-, tranexamic acid, Tranhexamic Acid, tranexamic acid (medication), Tranexamic Acid [Chemical/Ingredient], amca, amcas, acid tranexamic, TRANEXAMIC ACID, Tranexamic acid, Tranexamic acid (product), Tranexamic acid (substance)
Swedish Tranexamsyra
Czech kyselina tranexamová
Finnish Traneksaamihappo
Russian TRANEKSAMOVAIA KISLOTA, AMCHA, ТРАНЕКСАМОВАЯ КИСЛОТА
Japanese トラネキサム酸, ヘムロン, ヘキサトロン, トランサミン, アンビトフ, ウグロール, シクロカプロン
French Acide trans-4-(aminométhyl)-cyclohexanecarboxylique, Acide tranéxamique
Polish Kwas traneksamowy
Spanish ácido tranexámico (producto), ácido tranexámico (sustancia), ácido tranexámico, AMCHA, Ácido Tranexámico
German AMCHA, Tranexamsäure
Italian Acido tranesamico
Portuguese AMCHA, Ácido Tranexâmico

Ontology: Cyklokapron (C0591311)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D014148
English Pfizer Brand of Tranexamic Acid, cyklokapron, Cyklokapron

Ontology: Lysteda (C2726313)

Concepts Organic Chemical (T109) , Pharmacologic Substance (T121)
English Lysteda