What is the recommended dose of tranexamic acid (TXA) for treating fibroid-related bleeding?

Tranexamic Acid Dosing for Fibroid-Related Bleeding

For treating fibroid-related bleeding, tranexamic acid should be administered at a dose of 10-15 mg/kg followed by an infusion of 1-5 mg/kg per hour, or alternatively as 1.5-4 g daily in divided doses for 4-5 days starting from the first day of menstruation. 1, 2

Recommended Dosing Regimens

• The European guideline for management of bleeding recommends tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg per hour for fibrinolysis management 1
• For menorrhagia treatment, including fibroid-related bleeding, oral dosing of 3.9-4 g/day divided into 3-4 doses for 4-5 days starting from the first day of the menstrual cycle is recommended 2, 3
• Alternative effective dosing includes 1.5 g three times daily for 5 days (4.5 g/day) 2
• In clinical studies, tranexamic acid at these doses reduced menstrual blood loss by 34-59% over 2-3 cycles 2

Efficacy in Fibroid-Related Bleeding

• Tranexamic acid is a nonhormonal alternative agent that can reduce bleeding symptoms in patients with fibroids 1
• In women with menorrhagia, including those with fibroids, tranexamic acid therapy resulted in 34-54% reduction in menstrual blood loss 4
• Limited evidence indicates potential benefit specifically in fibroid patients with menorrhagia, though more research is needed 4, 5
• Quality-of-life parameters improved by 46-83% following tranexamic acid treatment in women with heavy menstrual bleeding 4

Mechanism of Action and Pharmacokinetics

• Tranexamic acid is a synthetic lysine analogue that competitively inhibits plasmin and plasminogen, preventing fibrin degradation 1
• The plasma half-life is approximately 120 minutes, requiring multiple daily doses or continuous infusion to maintain therapeutic levels 1
• In vitro studies suggest that a plasma concentration of 10 μg/ml is required to inhibit fibrinolysis 1

Safety Considerations

• Tranexamic acid should be used with caution in patients taking oral contraceptives due to increased thrombotic risk 6
• Dose adjustment is required in patients with renal dysfunction based on serum creatinine levels 6
• The most common adverse effects are gastrointestinal in nature (nausea, vomiting, diarrhea, dyspepsia) occurring in approximately 12% of patients 2
• Active thromboembolic disease is a contraindication to tranexamic acid use 3
• In the US, a history of thrombosis or thromboembolism, or an intrinsic risk for thrombosis are also considered contraindications 3
• No evidence exists of an increase in the incidence of thrombotic events with appropriate use 3

Clinical Considerations

• Antifibrinolytic therapy should be guided by thrombelastometric monitoring if possible and stopped once bleeding has been adequately controlled 1
• Tranexamic acid should be discontinued 5 days before high bleeding risk procedures or surgery in confined spaces 6
• For women with fibroids specifically, response may vary based on fibroid size and location 5
• Tranexamic acid is more effective at reducing menstrual blood loss than NSAIDs, etamsylate, and oral luteal phase norethisterone, but less effective than levonorgestrel-releasing intrauterine systems 2