Tranexamic acid

Last updated

Tranexamic acid
Tranexam.svg
Clinical data
Pronunciation\ˌtran-eks-ˌam-ik-\
Trade names Cyklokapron, others
Other namesTXA
AHFS/Drugs.com Monograph
MedlinePlus a612021
License data
Routes of
administration 		By mouth, intravenous, topical
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability 34%
Elimination half-life 3.1 h
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
PDB ligand
CompTox Dashboard (EPA)
ECHA InfoCard 100.013.471 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C8H15NO2
Molar mass 157.213 g·mol−1
3D model (JSmol)
  • NC[C@@H]1CC[C@H](CC1)C(O)=O
  • InChI=1S/C8H15NO2/c9-5-6-1-3-7(4-2-6)8(10)11/h6-7H,1-5,9H2,(H,10,11)/t6-,7- Yes check.svgY
  • Key:GYDJEQRTZSCIOI-LJGSYFOKSA-N Yes check.svgY
   (verify)

Tranexamic acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. [6] [7] It is also used for hereditary angioedema. [6] [2] It is taken either by mouth, injection into a vein, [6] or by intramuscular injection.

Contents

Tranexamic acid is a synthetic analog of the amino acid lysine. It serves as an antifibrinolytic by reversibly binding four to five lysine receptor sites on plasminogen. This decreases the conversion of plasminogen to plasmin, preventing fibrin degradation and preserving the framework of fibrin's matrix structure. [4] Tranexamic acid has roughly eight times the antifibrinolytic activity of an older analogue, ε-aminocaproic acid.[ citation needed ] Tranexamic acid also directly inhibits the activity of plasmin with weak potency (IC50 = 87 mM), [8] and it can block the active-site of urokinase plasminogen activator (uPA) with high specificity (Ki = 2 mM), one of the highest among all the serine proteases. [9]

Side effects are rare. [2] Some include changes in color vision, seizures, blood clots, and allergic reactions. [2] Tranexamic acid appears to be safe for use during pregnancy and breastfeeding. [2] [10] Tranexamic acid is an antifibrinolytic medication. [11]

Tranexamic acid was first made in 1962 by Japanese researchers Shosuke and Utako Okamoto. [12] It is on the World Health Organization's List of Essential Medicines. [13] Tranexamic acid is available as a generic drug. [14]

Uses

Medical uses

A one-gram ampoule of tranexamic acid TXAVial2017.jpg
A one-gram ampoule of tranexamic acid

Tranexamic acid is frequently used following major trauma. [15] Tranexamic acid is used to prevent and treat blood loss in a variety of situations, such as dental procedures, heavy menstrual bleeding, and surgeries with high risk of blood loss. [16] [17]

Trauma

Tranexamic acid has been found to decrease the risk of death due to any cause in people who have significant bleeding due to trauma. [18] [19] [20] [21] It is most effective if taken within the first three hours following major trauma. [22] It also decreases the risk of death if given within the first three hours of brain injury. [23]

Menstrual bleeding

Tranexamic acid is sometimes used to treat heavy menstrual bleeding. [17] When taken by mouth it both safely and effectively treats regularly occurring heavy menstrual bleeding and improves quality of life. [4] [24] [25] Another study demonstrated that the dose does not need to be adjusted in females who are between ages 12 and 16. [4] In a 10-year study, tranexamic acid and other oral medicines (mefenamic acid) were found to be as effective as the levonorgestrel intrauterine coil; the same proportion of women had not had surgery for heavy bleeding and had similar improvements in their quality of life. [26] [27]

Childbirth

Tranexamic acid is sometimes used (often in conjunction with oxytocin) to reduce bleeding after childbirth. [28] Death due to postpartum bleeding is reduced in women receiving tranexamic acid. [7]

Surgery

  • Tranexamic acid is sometimes used in orthopedic surgery to reduce blood loss, to the extent of reducing or altogether abolishing the need for perioperative blood transfusion. It is of proven value in clearing the field of surgery and reducing blood loss when given before or after surgery. Drain and number of transfusions are reduced. [29] [30] [31]
  • In surgical corrections of craniosynostosis in children it reduces the need for blood transfusions. [32]
  • In spinal surgery (e.g., scoliosis), correction with posterior spinal fusion using instrumentation, to prevent excessive blood loss. [33] [34]
  • In cardiac surgery, both with and without cardiopulmonary bypass (e.g., coronary artery bypass surgery), it is used to prevent excessive blood loss. [29]

Dentistry

In the United States, tranexamic acid is FDA-approved for short-term use in people with severe bleeding disorders who are about to have dental surgery. [35] Tranexamic acid is used for a short period before and after the surgery to prevent major blood loss and decrease the need for blood transfusions. [36]

Tranexamic acid is used in dentistry in the form of a 5% mouth rinse after extractions or surgery in patients with prolonged bleeding time; e.g., from acquired or inherited disorders. [37]

In China, tranexamic acid is allowed in over-the-counter toothpaste, with six products using the drug. As of 2018, there are no limits on dosage, nor requirements for labeling the concentration. [38] 0.05% TXA in toothpaste is allowed OTC in Hong Kong. [39] <5% TXA in over-the-counter toothpaste is first patented and marketed by Lion Corporation in Japan, [40] where it is still sold. [41] Presence of unauthorized TXA has led to the Canadian recall of a Yunnan Baiyao toothpaste in 2019. [42]

Hematology

There is not enough evidence to support the routine use of tranexamic acid to prevent bleeding in people with blood cancers. [43] However, several trials are currently assessing this use of tranexamic acid. [43] For people with inherited bleeding disorders (e.g. von Willebrand's disease), tranexamic acid is often given. [44] It has also been recommended for people with acquired bleeding disorders (e.g., directly acting oral anticoagulants (DOACs)) to treat serious bleeding. [45]

Nosebleeds

The use of tranexamic acid, applied directly to the area that is bleeding or taken by mouth, appears useful to treat nose bleeding compared to packing the nose with cotton pledgets alone. [46] [47] [48] It decreases the risk of rebleeding within 10 days. [49]

Cosmetic Uses

Tranexamic acid can be used in skincare products as a cosmetic active to reduce the appearance of inflammation and hyperpigmentation.[ citation needed ] Tranexamic acid is a zwitterion amino acid, and has a low permeability coefficient in the stratum corneum. [50] Tranexamic acid can be combined with penetration enhancers and microneedling to overcome this limitation. [51] Cosmetic uses may also employ lipophilic derivatives of tranexamic acid (ester prodrugs like Cetyl tranexamate mesylate) that are not zwitterionic and thus have improved skin permeability. [52] [53] [54]

Contraindications

Adverse effects

Side effects are rare. [2] Some reported adverse events include seizures, changes in color vision, blood clots, and allergic reactions such as anaphylaxis. [2] Whether the risk of venous thromboembolism (blood clots) is actually increased is a matter of debate. The risk is mentioned in the product literature, [4] and they were reported in post marketing experience. [4] Despite this, and the inhibitory effect of tranexamic acid on blood clot breakdown, large studies of the use of tranexamic acid have not shown an increase in the risk of venous or arterial thrombosis, [55] [56] even in people who had previously experienced thrombosis under other circumstances. [56]

Special populations

Society and culture

Tranexamic acid was first synthesized in 1962 by Japanese researchers Shosuke and Utako Okamoto. [12] It is on the World Health Organization's List of Essential Medicines. [13]

Brand names

Tranexamic acid is marketed in the US and Australia in tablet form as Lysteda [4] and in Australia, Sweden [58] and Jordan it is marketed in an IV form and tablet form as Cyklokapron, in the UK and Sweden [58] as Cyclo-F. In the UK it is also marketed as Femstrual, in Asia as Transcam, in Bangladesh as Intrax & Tracid, in India as Pause, in Pakistan as Transamin, in Indonesia as Kalnex, in South America as Espercil, in Japan as Nicolda, in France, Poland, Belgium, and Romania as Exacyl and in Egypt as Kapron. In the Philippines, its capsule form is marketed as Hemostan and in Israel as Hexakapron.[ citation needed ]

The US Food and Drug Administration (FDA) approved tranexamic acid oral tablets (brand name Lysteda) for the treatment of heavy menstrual bleeding in November 2009. [4] [59] [60]

In March 2011, the status of tranexamic acid for the treatment of heavy menstrual bleeding was changed in the UK, from POM (Prescription only Medicines) to P (Pharmacy Medicines) [61] and became available over the counter in UK pharmacies under the brand names of Cyklo-F and Femstrual. [62]

Research

Tranexamic acid might alleviate neuroinflammation in some experimental settings. [63]

Tranexamic acid can be used in case of postpartum hemorrhage; it can decrease the risk of death due to bleeding by one third according to the WHO. [64]

Tentative evidence supports the use of tranexamic acid in hemoptysis. [65] [66]

In hereditary angioedema [67]

In hereditary hemorrhagic telangiectasia: tranexamic acid has been shown to reduce the frequency of epistaxis in patients with severe and frequent nosebleed episodes from hereditary hemorrhagic telangiectasia. [68]

In melasma: tranexamic acid is sometimes used in skin whitening as a topical agent, injected into a lesion, or taken by mouth, both alone and as an adjunct to laser therapy; as of 2017 its safety seemed reasonable but its efficacy for this purpose was uncertain because there had been no large scale randomized controlled studies nor long term follow-up studies. [69] [70] It is allowed as a quasi-drug for skin whitening in Japan. [71]

In hyphema: tranexamic acid is effective in reducing the risk of secondary hemorrhage outcomes in people with traumatic hyphema. [72]

In liver resection: tranexamic acid did not reduce bleeding or transfusions but did increase complications. [73]

Related Research Articles

<span class="mw-page-title-main">Nonsteroidal anti-inflammatory drug</span> Class of therapeutic drug for relieving pain and inflammation

Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of use, but largely include an increased risk of gastrointestinal ulcers and bleeds, heart attack, and kidney disease.

<span class="mw-page-title-main">Gout</span> Form of arthritis causing swollen joints

Gout is a form of inflammatory arthritis characterized by recurrent attacks of pain in a red, tender, hot, and swollen joint, caused by the deposition of needle-like crystals of uric acid known as monosodium urate crystals. Pain typically comes on rapidly, reaching maximal intensity in less than 12 hours. The joint at the base of the big toe is affected (Podagra) in about half of cases. It may also result in tophi, kidney stones, or kidney damage.

Fibrinolysis is a process that prevents blood clots from growing and becoming problematic. Primary fibrinolysis is a normal body process, while secondary fibrinolysis is the breakdown of clots due to a medicine, a medical disorder, or some other cause.

<span class="mw-page-title-main">Dysmenorrhea</span> Pain during and sometimes before menstruation

Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea or nausea.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Bleeding of the esophagus, stomach, or upper intestine

Upper gastrointestinal bleeding (UGIB) is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

<span class="mw-page-title-main">Nosebleed</span> Bleeding from the nose

A nosebleed, also known as epistaxis, is an instance of bleeding from the nose. Blood can flow down into the stomach, and cause nausea and vomiting. In more severe cases, blood may come out of both nostrils. Rarely, bleeding may be so significant that low blood pressure occurs. Blood may also be forced to flow up and through the nasolacrimal duct and out of the eye, producing bloody tears.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

<span class="mw-page-title-main">Major trauma</span> Injury that could cause prolonged disability or death

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.

<span class="mw-page-title-main">Gastrointestinal bleeding</span> Bleeding in the gastrointestinal tract

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<span class="mw-page-title-main">Mefenamic acid</span> Chemical compound

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<span class="mw-page-title-main">Coagulopathy</span> Condition involving impaired blood clotting ability

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<span class="mw-page-title-main">Fresh frozen plasma</span> Liquid portion of whole blood

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<span class="mw-page-title-main">Aminocaproic acid</span> Chemical compound

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<span class="mw-page-title-main">Hyphema</span> Hemorrhage in the front chamber of the eye

Hyphema is the medical condition of bleeding in the anterior chamber of the eye between the iris and the cornea. People usually first notice a loss or decrease in vision. The eye may also appear to have a reddish tinge, or it may appear as a small pool of blood at the bottom of the iris in the cornea. A traumatic hyphema is caused by a blow to the eye. A hyphema can also occur spontaneously.

<span class="mw-page-title-main">Aprotinin</span> Antifibrinolytic molecule

The drug aprotinin, is a small protein bovine pancreatic trypsin inhibitor (BPTI), or basic trypsin inhibitor of bovine pancreas, which is an antifibrinolytic molecule that inhibits trypsin and related proteolytic enzymes. Under the trade name Trasylol, aprotinin was used as a medication administered by injection to reduce bleeding during complex surgery, such as heart and liver surgery. Its main effect is the slowing down of fibrinolysis, the process that leads to the breakdown of blood clots. The aim in its use was to decrease the need for blood transfusions during surgery, as well as end-organ damage due to hypotension as a result of marked blood loss. The drug was temporarily withdrawn worldwide in 2007 after studies suggested that its use increased the risk of complications or death; this was confirmed by follow-up studies. Trasylol sales were suspended in May 2008, except for very restricted research use. In February 2012 the European Medicines Agency (EMA) scientific committee reverted its previous standpoint regarding aprotinin, and has recommended that the suspension be lifted. Nordic became distributor of aprotinin in 2012.

<span class="mw-page-title-main">Platelet transfusion</span> Treatment for bleeding irregularities

Platelet transfusion, also known as platelet concentrate, is used to prevent or treat bleeding in people with either a low platelet count or poor platelet function. Often this occurs in people receiving cancer chemotherapy. Preventive transfusion is often done in those with platelet levels of less than 10 x 109/L. In those who are bleeding transfusion is usually carried out at less than 50 x 109/L. Blood group matching (ABO, RhD) is typically recommended before platelets are given. Unmatched platelets, however, are often used due to the unavailability of matched platelets. They are given by injection into a vein.

<span class="mw-page-title-main">Postpartum bleeding</span> Loss of blood following childbirth

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become restless or unconscious. In severe cases circulatory collapse, disseminated intravascular coagulation and death can occur. The condition can occur up to twelve weeks following delivery in the secondary form. The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who already have a low amount of red blood, are Asian, have a larger fetus or more than one fetus, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, those requiring the use of a vacuum or forceps, and those who have an episiotomy.

<span class="mw-page-title-main">Patient blood management</span> Set of medical practices

Patient Blood Management (PBM) is a set of medical practices designed to optimise the care of patients who might need a blood transfusion. Patient blood management programs use an organized framework to improve blood health, thus increasing patient safety and quality of life, reducing costs, and improving clinical outcomes. Some strategies to accomplish this include ensuring that anemia is treated prior to a surgical operation, using surgical techniques that limit blood loss, and returning blood lost during surgery to the patient via intraoperative blood salvage.

The fibrinolysis system is responsible for removing blood clots. Hyperfibrinolysis describes a situation with markedly enhanced fibrinolytic activity, resulting in increased, sometimes catastrophic bleeding. Hyperfibrinolysis can be caused by acquired or congenital reasons. Among the congenital conditions for hyperfibrinolysis, deficiency of alpha-2-antiplasmin or plasminogen activator inhibitor type 1 (PAI-1) are very rare. The affected individuals show a hemophilia-like bleeding phenotype. Acquired hyperfibrinolysis is found in liver disease, in patients with severe trauma, during major surgical procedures, and other conditions. A special situation with temporarily enhanced fibrinolysis is thrombolytic therapy with drugs which activate plasminogen, e.g. for use in acute ischemic events or in patients with stroke. In patients with severe trauma, hyperfibrinolysis is associated with poor outcome. Moreover, hyperfibrinolysis may be associated with blood brain barrier impairment, a plasmin-dependent effect due to an increased generation of bradykinin.

Haleema Shakur-Still is a professor of Global Health Clinical Trials and the co-director of London School of Hygiene & Tropical Medicine's Clinical Trials Unit.

References

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