Tranexamic Acid Safety in Patients with Stable Angina Using LNG-IUD
Tranexamic acid should be avoided in patients with stable angina using an LNG-IUD due to the FDA contraindication for patients with intrinsic risk for thrombosis or thromboembolism, and because stable angina represents underlying coronary artery disease that increases thrombotic risk. 1
Critical FDA Contraindications
The FDA explicitly contraindicates tranexamic acid in patients with: 1
- Active intravascular clotting
- History of thrombosis or thromboembolism
- Intrinsic risk for thrombosis or thromboembolism
Stable angina represents established coronary atherosclerosis, which constitutes an intrinsic thrombotic risk. 1
Thrombotic Risk with Tranexamic Acid
The FDA warns that tranexamic acid is an antifibrinolytic agent that may increase the risk of thromboembolic events, including venous and arterial thrombosis. 1 Reported events include: 1
- Deep vein thrombosis
- Pulmonary embolism
- Cerebral thrombosis
- Acute renal cortical necrosis
- Central retinal artery and vein obstruction
The American Heart Association specifically recommends avoiding tranexamic acid in women with spontaneous coronary artery dissection due to its association with myocardial infarction and thrombosis. 2
Contraceptive Interaction Concerns
The FDA explicitly warns against concomitant use of tranexamic acid with prothrombotic medical products, including hormonal contraceptives, as this further increases thrombotic risk. 1 While the LNG-IUD has primarily local effects, systemic absorption does occur, and cases of thromboembolism have been reported with tranexamic acid use in association with hormonal contraceptives. 1
Evidence Regarding Thrombotic Risk
A case-control study using the British General Practice Research Database found women taking tranexamic acid had a 3-fold higher risk of developing deep vein thrombosis (95% CI 0.7 to 15.8), though the wide confidence interval indicates the true risk could be substantially higher. 3
The thrombotic risk is particularly concerning when bleeding is not life-threatening, as the risk-benefit calculation shifts unfavorably. 3
Alternative Management for LNG-IUD Bleeding
Importantly, heavy or prolonged bleeding is uncommon during LNG-IUD use, and no direct evidence supports therapeutic treatments for bleeding irregularities during LNG-IUD use. 4, 5 The CDC guidelines note: 4, 5
- Unscheduled spotting or light bleeding is expected during the first 3-6 months of LNG-IUD use
- Bleeding generally decreases with continued use
- Many women experience only light menstrual bleeding or amenorrhea over time
If bleeding occurs with LNG-IUD, first evaluate for: 4, 5
- IUD displacement
- Sexually transmitted infections or pelvic inflammatory disease
- Pregnancy
- New pathologic uterine conditions (polyps, fibroids)
Safer Alternatives
For patients with stable angina requiring treatment for menstrual bleeding:
- NSAIDs (mefenamic acid, ibuprofen) are safer first-line options that reduce menstrual blood loss without the thrombotic risk of tranexamic acid 4, 6
- Consider removing the LNG-IUD and offering alternative contraception if bleeding persists and is unacceptable 4, 5
Common Pitfall to Avoid
Do not assume that because large trauma trials showed no increased thrombotic risk with tranexamic acid 7, the drug is safe in patients with pre-existing cardiovascular disease. The trauma data involved acute hemorrhagic shock with hemoconcentration, which differs fundamentally from the prothrombotic state of stable coronary disease. 3