Introduction
Tranexamic acid (TXA) is a synthetic lysine derivative that inhibits fibrinolysis by blocking the lysine binding sites on plasminogen. Plasminogen is an inactive form of plasmin which acts to dissolve fibrin clots.
Key Points
- Tranexamic acid is a synthetic lysine derivative that inhibits fibrinolysis by blocking lysine binding sites on plasminogen, stabilizing fibrin clots.
- TXA offers a route-flexible option for several minor bleeding presentations — including topical/soaked gauze for anterior epistaxis and dental bleeding.
- Across the cited studies, TXA was associated with stopped or reduced bleeding compared with its respective comparators.
- Rapid IV administration may cause hypotension; use caution in patients on oral contraceptives and those with clotting disorders.
Clinical Detail
| Properties | Tranexamic Acid (TXA) |
|---|---|
| Dose | Epistaxis: 500–1000 mg via topical nasal gauze Heavy Menstrual Bleeding: 1.3 g PO TID Hemoptysis: 500 mg via nebulizer |
| Formulation | IV 1000 mg/10 ml vial 650 mg tablets |
| PK/PD | Onset IV: 1–5 hours Time to Peak Concentration PO: 2.5–3 hours; IV: 5 minutes Duration PO: 24 hours; IV: 17 hours Excretion: Urine (>95% as unchanged drug) |
| Adverse Effects | Rapid administration could cause hypotension |
| Drug Interactions and Warnings | Caution in women taking oral contraceptives, patients with clotting disorders, and those taking chlorpromazine |
| Compatibility | Compatible with Normal Saline and Dextrose solutions |
Directions for Administration by Indication
| Indication | Directions |
|---|---|
| Anterior Epistaxis | Consider using 500–1,000 mg of TXA (5–10 ml) to soak gauze/pledget and insert it into the nasal cavity for ~30 min |
| Heavy Menstrual Bleeding | Consider administering 1300 mg of oral TXA tablets TID x 7 days |
| Hemoptysis | Consider mixing 500–1000 mg of TXA (5–10 ml) with 5–10 ml of NS then administer via nebulizer |
| Dental Bleeding | Consider dissolving 1–2 650 mg TXA tablets in 10 mL distilled water, then swish for two minutes followed by expectoration |
Evidence
| Author, year | Indication | Intervention & Comparison | Outcome |
|---|---|---|---|
| Bryant-Smith (Cochrane), 2018 | Heavy menstrual bleeding | TXA* | TXA associated with a reduced blood loss of −53.20 to −73 ml per cycle and ↑ likelihood of improvement. Effective for treating HMB compared to placebo, NSAIDs, oral luteal progestogens |
| Lukes, 2010 | Heavy menstrual bleeding | TXA 1300 mg PO TID x 7 days | TXA had greater ↓ in menstrual blood loss, ↓ menstrual blood loss exceeding 50 mL, and ↑ QOL compared with women receiving placebo |
| Zirk, 2018 | Dental Bleeding | TXA soaked gauze* | TXA provided ↑ chance to stop oral bleeding event by a factor of 1.6 over gauze alone |
| Nuvvula, 2014 | Dental Bleeding | Dissolved 500 mg TXA tablets in 10 mL distilled water | Topical TXA was non-inferior and an effective alternative to factor therapy in controlling gingival hemorrhage. |
| Zahed, 2018 | Anterior Epistaxis | Topical TXA 500 mg soaked gauze | Bleeding was stopped in 73% of the patients in the TXA group, compared with 29% in the ANP group. At 1 week, rebleeding was 5% vs 21% in TXA and nasal packing respectively |
| Zahed, 2013 | Anterior Epistaxis | Topical TXA 500 mg soaked gauze | Within 10 minutes of treatment, bleeding stopped in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group |
| Wand, 2018 | Hemoptysis | Nebulized TXA 500 mg/5 ml | ↑ Rate of complete resolution of hemoptysis during first 5 days, ↓ LOS, and ↓ daily volume of expectorated blood |
| Solomonov, 2009 | Hemoptysis | Nebulized TXA 500 mg/5 ml | In all cases, the bleeding stopped with the first dose of TXA and was well tolerated without adverse events |
* Dose not recorded
Conclusions
- Tranexamic acid (TXA) is a synthetic lysine derivative that inhibits fibrinolysis by blocking lysine binding sites on plasminogen, stabilizing the fibrin clot.
- TXA offers a route-flexible option for several minor bleeding presentations on this page — topical/soaked gauze for anterior epistaxis and dental bleeding, oral dosing for heavy menstrual bleeding, and nebulized administration for hemoptysis.
- Across the cited studies, TXA was associated with stopped or reduced bleeding compared with its respective comparators (e.g., anterior nasal packing, placebo, or gauze alone) and was generally well tolerated.
- Rapid IV administration may cause hypotension, and caution is warranted in patients on oral contraceptives, those with clotting disorders, and those taking chlorpromazine.
References
Tranexamic acid. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved September 6, 2018, from http://www.micromedexsolutions.com/
Bryant-Smith AC et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018 Apr 15;4. PMID: 29656433.
Lukes AS et al. Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010 Oct;116(4):865-75. PMID: 20859150
Zirk M et al. Supportive topical tranexamic acid application for hemostasis in oral bleeding events – Retrospective cohort study of 542 patients. J Craniomaxillofac Surg. 2018 Jun;46(6):932-936. PMID: 29627368
Nuvvula S et al. Efficacy of tranexamic acid mouthwash as an alternative for factor replacement in gingival bleeding during dental scaling in cases of hemophilia: A randomized clinical trial. Contemp Clin Dent. 2014 Jan-Mar; 5(1): 49-53. PMID: 24808695
Zahed R et al. A New and Rapid Method for Epistaxis Treatment Using Injectable arm of Tranexamic Acid Topically: A Randomized Controlled Trial Am J Emerg Med 2013. PMID: 23911102
Zahed R et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med. 2018 Mar;25(3):261-266. PMID: 29125679
Wand O et al. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. CHEST 2018. PMID: 30321510
Solomonov A et al. Pulmonary hemorrhage: A novel mode of therapy. Respir Med. 2009 Aug;103(8):1196-200.
How To Place An Epistaxis TXA Pack. https://www.youtube.com/watch?v=ekGsM9CZSpY
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