What are the contraindications for Tranexamic Acid (TXA)?

Contraindications for Tranexamic Acid (TXA)

Tranexamic acid is absolutely contraindicated in patients with subarachnoid hemorrhage, active intravascular clotting, and hypersensitivity to tranexamic acid or any of its ingredients. 1

Absolute Contraindications

• Subarachnoid hemorrhage: TXA can cause cerebral edema and cerebral infarction in these patients 1
• Active intravascular clotting: As an antifibrinolytic agent, TXA may worsen ongoing thrombosis 1
• Hypersensitivity to tranexamic acid or any components of the formulation 1

Relative Contraindications and Cautions

Thromboembolic Risk

• History of thromboembolism: Use with caution, though recent evidence suggests TXA may be safe in selected patients with history of venous thromboembolism 2
• Concomitant use with prothrombotic medications: Avoid using with Factor IX Complex concentrates, Anti-inhibitor Coagulant concentrates, and hormonal contraceptives 1

Specific Clinical Scenarios

• Massive hematuria: Risk of ureteric obstruction due to clot formation 3
• Hyperfibrinolytic DIC: In cancer-related disseminated intravascular coagulation (DIC), TXA should not be routinely used except when therapy-resistant bleeding dominates the clinical picture 4
• High-dose IV TXA in gastrointestinal bleeding: Not recommended due to increased risk of thrombotic events without significant benefit 4

Dosage Adjustments Required

• Renal impairment: Dose adjustment required based on serum creatinine levels 3:
  • Creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily
  • Creatinine 2.83-5.66 mg/dL: 10 mg/kg daily
  • Creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours

Adverse Effects to Monitor

1. Seizures: Particularly with high doses (>2 g/day) 5

   • Risk increases with dose 5
   • Consider EEG monitoring in patients with history of seizures 1

2. Thromboembolic events:

   • Deep vein thrombosis
   • Pulmonary embolism
   • Arterial thrombosis
   • Though meta-analyses show no significant increase in thromboembolic events with standard dosing 6

3. Visual disturbances:

   • Consider ophthalmic monitoring for patients treated >3 months 1
   • Discontinue if changes in ophthalmological examination occur

4. Other adverse effects:

   • Dizziness
   • Hypotension
   • Nausea/vomiting
   • Allergic reactions (including anaphylaxis) 1

Administration Considerations

• Route of administration: TXA is for intravenous use only; serious adverse reactions including seizures and cardiac arrhythmias have occurred with inadvertent intrathecal administration 1
• Timing: Maximum benefit achieved when administered within 3 hours of injury/bleeding onset; should NOT be administered after 3 hours as it may increase mortality risk 3
• Duration: Consider discontinuing once bleeding is adequately controlled 3

Special Populations

• Elderly patients: Maximum total dose of 100 mg/kg recommended, especially in patients over 50 years of age, to reduce risk of neurotoxicity 7
• Pregnancy: Not contraindicated in postpartum hemorrhage; in fact, TXA is recommended for moderate to severe postpartum bleeding 4

When considering TXA administration, carefully weigh the benefits of reduced bleeding against the potential risks, particularly in patients with risk factors for thrombosis. The evidence suggests that with proper patient selection and appropriate dosing, TXA has a favorable safety profile in most clinical scenarios.