What is the role of Tranexamic acid (TXA) in Hemophilia A?

From the Guidelines

Tranexamic acid (Tranexa) is contraindicated in conjunction with activated prothrombin complex concentrate (aPCC) administration in patients with hemophilia A, as stated in the prescribing information 1. When considering the use of Tranexa in hemophilia A, it is crucial to weigh the potential benefits against the risks, particularly in the context of other treatments being used.

• The primary concern with using Tranexa alongside aPCC is the increased risk of thromboembolic complications, which could significantly impact morbidity, mortality, and quality of life.
• In general, Tranexa works as an antifibrinolytic agent by inhibiting plasminogen activation, which can be beneficial in managing bleeding episodes in hemophilia A patients by preventing clot breakdown and helping maintain clot stability 1.
• However, the specific contraindication with aPCC limits its use in certain scenarios, emphasizing the need for careful consideration of the treatment regimen for each patient.
• For patients with hemophilia A not receiving aPCC, Tranexa could potentially be used as an adjunctive therapy to factor replacement, especially for mucosal bleeding where fibrinolysis is active, but this should be decided on a case-by-case basis considering the latest clinical guidelines and patient-specific factors.
• It's also important to note that while Tranexa may be beneficial in some contexts, it should not replace factor replacement therapy for major bleeding episodes, and its use should be cautious in patients with a history of thromboembolic events or hematuria, with necessary dose adjustments in renal impairment 1.

From the FDA Drug Label

Tranexamic acid is an antifibrinolytic indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction. Tranexamic acid injection is indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction. Tranexamic acid is an antifibrinolytic indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction (1)

Tranexa (tranexamic acid) is indicated for use in patients with hemophilia to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction, for short-term use of 2 to 8 days 2, 2, 2.

• The dosage for patients with hemophilia is 10 mg/kg actual body weight of Tranexamic acid injection intravenously with replacement therapy before extraction, and 10 mg/kg actual body weight 3 to 4 times daily for 2 to 8 days after extraction 2.
• Contraindications include subarachnoid hemorrhage, active intravascular clotting, and severe hypersensitivity reactions to tranexamic acid or any of the ingredients 2.

From the Research

Tranexamic Acid in Hemophilia A

• Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to improve hemostasis in patients with hemophilia A, particularly in those with inhibitors 3.
• A study published in 2012 reported the use of TXA in combination with activated prothrombin complex concentrate (APCC) in patients with hemophilia A and inhibitors, and found that the combination was safe and effective in managing bleeding episodes and preventing hemorrhage during surgery 3.
• Another study published in 2021 reviewed the evidence for TXA in the prevention and treatment of bleeding in surgery, trauma, and bleeding disorders, and found that TXA reduces bleeding in patients with menorrhagia, and in patients undergoing various surgical procedures, including orthopedic and cardiac surgery 4.
• A preclinical study published in 2020 investigated the hemostatic effect of TXA combined with factor VIII concentrate in a prophylactic setting in severe hemophilia A, and found that the addition of TXA improved hemostasis and reduced joint bleeding in factor VIII knockout mice 5.

Desmopressin in Hemophilia A

• Desmopressin is a synthetic vasopressin analogue that increases plasma concentrations of factor VIII and von Willebrand factor, and is commonly used to treat mild hemophilia A and von Willebrand disease 6, 7.
• Desmopressin has been shown to be effective in increasing factor VIII levels and reducing bleeding episodes in patients with mild hemophilia A, but its effectiveness depends on the patient's basal factor VIII level and the post-desmopressin plasma concentration of factor VIII 6, 7.
• A study published in 2008 reviewed the use of desmopressin for the treatment of hemophilia, and found that desmopressin is a safe and effective treatment option for patients with mild hemophilia A and factor VIII coagulant activity > 5% 7.

Combination Therapy

• The combination of TXA and desmopressin has not been extensively studied in patients with hemophilia A, but the available evidence suggests that TXA may be a useful adjunct to factor VIII replacement therapy in patients with severe hemophilia A 5.
• Further studies are needed to investigate the safety and efficacy of combination therapy with TXA and desmopressin in patients with hemophilia A.