How should tranexamic acid 650 mg tablets be prescribed (dose, frequency, duration, dispense quantity, and refill) for a menstruating woman with heavy menstrual bleeding and no contraindications?

Tranexamic Acid Prescription for Heavy Menstrual Bleeding

The prescription as written is correct: tranexamic acid 650 mg, 2 tablets (1,300 mg) orally three times daily (total 3.9 g/day) for up to 5 days starting on day 1 of menstrual bleeding, with 90 tablets dispensed and 1 refill, is the FDA-approved dosing regimen for heavy menstrual bleeding. 1, 2

Dosing Regimen Validation

• The total daily dose of 3.9-4 g/day for 4-5 days starting from the first day of menstruation is the evidence-based standard. 1, 2, 3
• Each dose should be 1,300 mg (two 650 mg tablets) taken three times daily, maintaining plasma concentrations within the therapeutic range of 5-15 μg/mL. 4
• Treatment is limited to menstruation days only (maximum 5 days per cycle), not continuous therapy. 1, 5

Efficacy Expectations

• Tranexamic acid reduces menstrual blood loss by 34-60%, which is significantly more effective than NSAIDs, oral progestins, or placebo. 1, 2, 5
• The levonorgestrel-releasing IUD is more effective (71-95% reduction) and should be considered if the patient desires long-term management or contraception. 1, 6

Critical Safety Screening Required Before Dispensing

Absolute contraindications that must be ruled out: 1, 7

• Active thromboembolic disease (DVT, PE, stroke)
• History of thrombosis or thromboembolism
• Cardiovascular disease (increased MI and thrombosis risk)
• Intrinsic risk factors for thrombosis

Food Administration

• Taking with food is appropriate and does not significantly affect absorption of the modified-immediate-release formulation. 4
• Food does not appreciably influence tranexamic acid pharmacokinetics for this formulation. 4

Dispense Quantity Justification

• 90 tablets with 1 refill provides coverage for 3 menstrual cycles (30 tablets per 5-day treatment period). 3
• This allows adequate trial duration to assess efficacy, as clinical studies demonstrate effectiveness over 2-3 cycles. 3

Common Pitfalls to Avoid

• Never prescribe tranexamic acid for continuous daily use—it is only for menstruation days. 1, 5
• Do not combine with hormonal contraceptives containing estrogen, as this increases thrombotic risk. 7
• If contraception is needed, use copper IUD or barrier methods only, though the levonorgestrel IUD would be superior for treating both bleeding and contraception. 7, 6
• Discontinue immediately if patient develops visual disturbances, severe headache, or signs of thrombosis. 2

Expected Tolerability

• Adverse effects are predominantly mild gastrointestinal symptoms (nausea, vomiting, diarrhea, dyspepsia) occurring in approximately 12% of patients. 3
• No evidence exists of increased thrombotic events in women without pre-existing risk factors. 2

When to Reassess Treatment Choice

• If the patient requires both contraception and bleeding control, switch to levonorgestrel-releasing IUD, which reduces bleeding by 71-95% versus tranexamic acid's 34-60% and provides superior contraception. 7, 6
• If NSAIDs have not been tried and the patient has no cardiovascular contraindications, consider NSAIDs as first-line therapy for 5-7 days during menstruation. 1, 6