Tranexamic Acid

TRANEXAMIC ACID- tranexamic acid tablet
Golden State Medical Supply, Inc.

1 INDICATIONS AND USAGE

Tranexamic acid tablets are indicated for the treatment of cyclic heavy menstrual bleeding [see Clinical Studies (14) ].

Prior to prescribing tranexamic acid tablets, exclude endometrial pathology that can be associated with heavy menstrual bleeding.

2 DOSAGE AND ADMINISTRATION

2.1 Recommended Dosage

The recommended dose of tranexamic acid for women with normal renal function is two 650 mg tablets taken three times daily (3900 mg/day) for a maximum of 5 days during monthly menstruation. Tranexamic acid tablets may be administered without regard to meals. Tablets should be swallowed whole and not chewed or broken apart.

2.2 Renal Impairment

In patients with renal impairment, the plasma concentration of tranexamic acid increased as serum creatinine concentration increased [see Clinical Pharmacology (12.3) ]. Dosage adjustment is needed in patients with serum creatinine concentration higher than 1.4 mg/dL (Table 1).

Table 1. Dosage of Tranexamic acid in Patients with Renal Impairment
Tranexamic acid
Serum Creatinine
(mg/dL)
Adjusted Dose Total Daily Dose

Cr above 1.4 and
≤ 2.8

1300 mg (two 650 mg tablets) two times a day for a maximum of 5 days during menstruation

2600 mg

Cr above 2.8 and
≤ 5.7

1300 mg (two 650 mg tablets) once a day for a maximum of 5 days during menstruation

1300 mg

Cr above 5.7

650 mg (one 650 mg tablet) once a day for a maximum of 5 days during menstruation

650 mg

3 DOSAGE FORMS AND STRENGTHS

650 mg tablets

4 CONTRAINDICATIONS

4.1 Thromboembolic Risk

Do not prescribe tranexamic acid tablets to women who are

1.
using combination hormonal contraception
2.
known to have any of the following conditions:
Active thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, or cerebral thrombosis)
A history of thrombosis or thromboembolism, including retinal vein or artery occlusion
An intrinsic risk of thrombosis or thromboembolism (e.g., thrombogenic valvular disease, thrombogenic cardiac rhythm disease, or hypercoagulopathy)

Venous and arterial thrombosis or thromboembolism, as well as cases of retinal artery and retinal vein occlusions, have been reported with tranexamic acid.

4.2 Hypersensitivity to Tranexamic Acid

Do not prescribe tranexamic acid tablets to women with known hypersensitivity to tranexamic acid [see Warnings and Precautions (5.2) and Adverse Reactions (6.1)].

5 WARNINGS AND PRECAUTIONS

5.1 Thromboembolic Risk

Concomitant Use of Hormonal Contraceptives

Combination hormonal contraceptives are known to increase the risk of venous thromboembolism, as well as arterial thromboses such as stroke and myocardial infarction. Because tranexamic acid is antifibrinolytic, the risk of venous thromboembolism, as well as arterial thromboses such as stroke, may increase further when hormonal contraceptives are administered with tranexamic acid. This is of particular concern in women who are obese or smoke cigarettes, especially smokers over 35 years of age.

Women using hormonal contraception were excluded from the clinical trials supporting the safety and efficacy of tranexamic acid, and there are no clinical trial data on the risk of thrombotic events with the concomitant use of tranexamic acid with hormonal contraceptives. However, there have been US postmarketing reports of venous and arterial thrombotic events in women who have used tranexamic acid concomitantly with combination hormonal contraceptives. For this reason, concomitant use of tranexamic acid with combination hormonal contraceptives is contraindicated. [see Contraindications (4.1) and Drug Interactions (7.1)].

Factor IX Complex Concentrates or Anti-Inhibitor Coagulant Concentrates

Tranexamic acid is not recommended for women taking either Factor IX complex concentrates or anti-inhibitor coagulant concentrates because the risk of thrombosis may be increased [see Drug Interactions (7.3) and Clinical Pharmacology (12.3) ].

All-Trans Retinoic Acid (Oral Tretinoin)

Exercise caution when prescribing tranexamic acid to women with acute promyelocytic leukemia taking all-trans retinoic acid for remission induction because of possible exacerbation of the procoagulant effect of all-trans retinoic acid [see Drug Interactions (7.4) and Clinical Pharmacology (12.3) ].

Ocular Effects

Retinal venous and arterial occlusion has been reported in patients using tranexamic acid. Patients should be instructed to report visual and ocular symptoms promptly. In the event of such symptoms, patients should be instructed to discontinue tranexamic acid immediately and should be referred to an ophthalmologist for a complete ophthalmic evaluation, including dilated retinal examination, to exclude the possibility of retinal venous or arterial occlusion.

5.2 Severe Allergic Reaction

A case of severe allergic reaction to tranexamic acid was reported in the clinical trials, involving a subject who experienced dyspnea, tightening of her throat, and facial flushing that required emergency medical treatment. A case of anaphylactic shock has also been reported in the literature, involving a patient who received an intravenous bolus of tranexamic acid.

5.3 Subarachnoid Hemorrhage

Cerebral edema and cerebral infarction may be caused by use of tranexamic acid in women with subarachnoid hemorrhage.

5.4 Ligneous Conjunctivitis

Ligneous conjunctivitis has been reported in patients taking tranexamic acid. The conjunctivitis resolved following cessation of the drug.

6 ADVERSE REACTIONS

6.1 Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

Short-term Studies

The safety of tranexamic acid in the treatment of heavy menstrual bleeding (HMB) was studied in two randomized, double-blind, placebo-controlled studies [see Clinical Studies (14) ]. One study compared the effects of two doses of tranexamic acid (1950 mg and 3900 mg given daily for up to 5 days during each menstrual period) versus placebo over a 3-cycle treatment duration. A total of 304 women were randomized to this study, with 115 receiving at least one dose of 3900 mg/day of tranexamic acid. A second study compared the effects of tranexamic acid (3900 mg/day) versus placebo over a 6-cycle treatment duration. A total of 196 women were randomized to this study, with 117 receiving at least one dose of tranexamic acid. In both studies, subjects were generally healthy women who had menstrual blood loss of ≥ 80 mL.

In these studies, subjects were 18 to 49 years of age with a mean age of approximately 40 years, had cyclic menses every 21 to 35 days, and a BMI of approximately 32 kg/m2. On average, subjects had a history of HMB for approximately 10 years and 40% had fibroids as determined by transvaginal ultrasound. Approximately 70% were Caucasian, 25% were Black, and 5% were Asian, Native American, Pacific Islander, or Other. Seven percent (7%) of all subjects were of Hispanic origin. Women using hormonal contraception were excluded from the trials.

The rates of discontinuation due to adverse events during the two clinical trials were comparable between tranexamic acid and placebo. In the 3-cycle study, the rate in the 3900 mg tranexamic acid dose group was 0.8% as compared to 1.4% in the placebo group. In the 6-cycle study, the rate in the tranexamic acid group was 2.4% as compared to 4.1% in the placebo group. Across the studies, the combined exposure to 3900 mg/day tranexamic acid was 947 cycles and the average duration of use was 3.4 days per cycle.

A list of adverse events occurring in ≥ 5% of subjects and more frequently in tranexamic acid treated subjects receiving 3900 mg/day compared to placebo is provided in Table 2.

Table 2. Adverse Events Reported by ≥ 5% of Subjects Treated with Tranexamic Acid and More Frequently in Tranexamic Acid-Treated Subjects

Tranexamic acid
3900 mg/day n (%)
(N=232)

Placebo
n (%)
(N=139)
*
Includes headache and tension headache
Nasal and sinus symptoms include nasal, respiratory tract and sinus congestion, sinusitis, acute sinusitis, sinus headache, allergic sinusitis and sinus pain, and multiple allergies and seasonal allergies
Abdominal pain includes abdominal tenderness and discomfort
§
Musculoskeletal pain includes musculoskeletal discomfort and myalgia
Arthralgia includes joint stiffness and swelling

Total Number of Adverse Events

1500

923

Number of Subjects with at Least One Adverse Event

208 (89.7%)

122 (87.8%)

HEADACHE *

117 (50.4%)

65 (46.8%)

NASAL & SINUS SYMPTOMS

59 (25.4%)

24 (17.3%)

BACK PAIN

48 (20.7%)

21 (15.1%)

ABDOMINAL PAIN

46 (19.8%)

25 (18.0%)

MUSCULOSKELETAL PAIN §

26 (11.2%)

4 (2.9%)

ARTHRALGIA

16 (6.9%)

7 (5.0%)

MUSCLE CRAMPS & SPASMS

15 (6.5%)

8 (5.8%)

MIGRAINE

14 (6.0%)

8 (5.8%)

ANEMIA

13 (5.6%)

5 (3.6%)

FATIGUE

12 (5.2%)

6 (4.3%)

Long-term Studies

Long-term safety of tranexamic acid was studied in two open-label studies. In one study, subjects with physician-diagnosed heavy menstrual bleeding (not using the alkaline hematin methodology) were treated with 3900 mg/day for up to 5 days during each menstrual period for up to 27 menstrual cycles. A total of 781 subjects were enrolled and 239 completed the study through 27 menstrual cycles. A total of 12.4% of the subjects withdrew due to adverse events. Women using hormonal contraception were excluded from the study. The total exposure in this study to 3900 mg/day tranexamic acid was 10,213 cycles. The average duration of tranexamic acid use was 2.9 days per cycle.

A long-term open-label extension study of subjects from the two short-term efficacy studies was also conducted in which subjects were treated with 3900 mg/day for up to 5 days during each menstrual period for up to 9 menstrual cycles. A total of 288 subjects were enrolled and 196 subjects completed the study through 9 menstrual cycles. A total of 2.1% of the subjects withdrew due to adverse events. The total exposure to 3900 mg/day tranexamic acid in this study was 1,956 cycles. The average duration of tranexamic acid use was 3.5 days per cycle.

The types and severity of adverse events in these two long-term open-label trials were similar to those observed in the double-blind, placebo-controlled studies although the percentage of subjects reporting them was greater in the 27-month study, most likely because of the longer study duration.

A case of severe allergic reaction to tranexamic acid was reported in the extension trial, involving a subject on her fourth cycle of treatment, who experienced dyspnea, tightening of her throat, and facial flushing that required emergency medical treatment.

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