Tranexamic acid (oral)

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# Overview
Tranexamic acid (oral) is an antifibrinolytic agent that is FDA approved for the treatment of cyclic heavy menstrual bleeding.   Common adverse reactions include headache, sinus and nasal symptoms, back pain, abdominal pain, musculoskeletal pain, joint pain, muscle cramps, migraine, anemia, and fatigue.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

## Indications
- Tranexamic acid Tablets is indicated for the treatment of cyclic heavy menstrual bleeding.
- Prior to prescribing tranexamic acid, exclude endometrial pathology that can be associated with heavy menstrual bleeding.

## Dosage

### 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 may be administered without regard to meals. Tablets should be swallowed whole and not chewed or broken apart.

### Renal Impairment
- In patients with renal impairment, the plasma concentration of tranexamic acid increased as serum creatinine concentration increased. Dosage adjustment is needed in patients with serum creatinine concentration higher than 1.4 mg/dL (Table 1).

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Tranexamic acid (oral) in adult patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Tranexamic acid (oral) in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- Tranexamic acid is indicated for women of reproductive age and is not intended for use in premenarcheal girls.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
- There is limited information regarding Off-Label Guideline-Supported Use of Tranexamic acid (oral) in pediatric patients.

### NonGuideline-Supported Use
- There is limited information regarding Off-Label NonGuideline-Supported Use of Tranexamic acid (oral) in pediatric patients.

# Contraindications

## Thromboembolic Risk
- Do not prescribe tranexamic acid to women who are
- using combination hormonal contraception
- 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.

## Hypersensitivity to Tranexamic Acid
- Do not prescribe tranexamic acid to women with known hypersensitivity to tranexamic acid

# Warnings

## 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.
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.
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.
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.

## 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.

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

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

# Adverse Reactions

## Clinical Trials 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. 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 21-35 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.

### 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.

## Postmarketing Experience
- The following adverse reactions have been identified from postmarketing experience with tranexamic acid. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
- Based on US and worldwide postmarketing reports, the following have been reported in patients receiving tranexamic acid for various indications:
- Nausea, vomiting, and diarrhea
- Allergic skin reactions
- Anaphylactic shock and anaphylactoid reactions
- Thromboembolic events (e.g., deep vein thrombosis, pulmonary embolism, cerebral thrombosis, acute renal cortical necrosis, and central retinal artery and vein obstruction); cases have been associated with concomitant use of combination hormonal contraceptives
- Impaired color vision and other visual disturbances
- Dizziness

# Drug Interactions

## Hormonal Contraceptives
- Because tranexamic acid is antifibrinolytic, concomitant use of hormonal contraception and tranexamic acid may further exacerbate the increased thrombotic risk associated with combination hormonal contraceptives. For this reason, concomitant use of tranexamic acid with combination hormonal contraceptives is contraindicated.

## Tissue Plasminogen Activators
- Concomitant therapy with tissue plasminogen activators may decrease the efficacy of both tranexamic acid and tissue plasminogen activators. Therefore, exercise caution if a woman taking tranexamic acid therapy requires tissue plasminogen activators.

## 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.

## 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.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): B
- Tranexamic acid is not indicated for use in pregnant women. Reproduction studies have been performed in mice, rats and rabbits and have revealed no evidence of impaired fertility or harm to the fetus due to tranexamic acid. However, tranexamic acid is known to cross the placenta and appears in cord blood at concentrations approximately equal to the maternal concentration. There are no adequate and well-controlled studies in pregnant women.
- An embryo-fetal developmental toxicity study in rats and a perinatal developmental toxicity study in rats were conducted using tranexamic acid. No adverse effects were observed in either study at doses up to 4 times the recommended human oral dose of 3900 mg/day based on mg/m2 (actual animal dose 1500 mg/kg/day).
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Tranexamic acid (oral) in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Tranexamic acid (oral) during labor and delivery.

### Nursing Mothers
- Tranexamic acid is present in the mother's milk at a concentration of about one hundredth of the corresponding serum concentration. Tranexamic acid should be used during lactation only if clearly needed.

### Pediatric Use
- Tranexamic acid is indicated for women of reproductive age and is not intended for use in premenarcheal girls.
- Based on a pharmacokinetic study in 20 adolescent females, 12 to 16 years of age, no dose adjustment is needed in the adolescent population.

### Geriatic Use
- Tranexamic acid is indicated for women of reproductive age and is not intended for use by postmenopausal women.

### Gender
There is no FDA guidance on the use of Tranexamic acid (oral) with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Tranexamic acid (oral) with respect to specific racial populations.

### Renal Impairment
- The effect of renal impairment on the pharmacokinetics of tranexamic acid has not been studied. Because tranexamic acid is primarily eliminated via the kidneys by glomerular filtration with more than 95% excreted as unchanged in urine, dosage adjustment in patient with renal impairment is needed.

### Hepatic Impairment
- The effect of hepatic impairment on the pharmacokinetics of tranexamic acid has not been studied. Because only a small fraction of the drug is metabolized, dosage adjustment in patients with hepatic impairment is not needed.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Tranexamic acid (oral) in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Tranexamic acid (oral) in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral

### Monitoring
- There is limited information regarding drug monitoring.

# IV Compatibility
- There is limited information regarding IV Compatibility.

# Overdosage
- There are no known cases of intentional overdose with tranexamic acid and no subjects in the clinical program took more than 2 times the prescribed amount of tranexamic acid in a 24-hour period (>7800 mg/day). However, cases of overdose of tranexamic acid have been reported. Based on these reports, symptoms of overdose may include gastrointestinal (nausea, vomiting, diarrhea); hypotensive (e.g., orthostatic symptoms); thromboembolic (arterial, venous, embolic); visual impairment; mental status changes; myoclonus; or rash. No specific information is available on the treatment of overdose with tranexamic acid. In the event of overdose, employ the usual supportive measures (e.g., clinical monitoring and supportive therapy) as dictated by the patient's clinical status.

# Pharmacology

## Mechanism of Action
- Tranexamic acid is a synthetic lysine amino acid derivative, which diminishes the dissolution of hemostatic fibrin by plasmin. In the presence of tranexamic acid, the lysine receptor binding sites of plasmin for fibrin are occupied, preventing binding to fibrin monomers, thus preserving and stabilizing fibrin's matrix structure.
- The antifibrinolytic effects of tranexamic acid are mediated by reversible interactions at multiple binding sites within plasminogen. Native human plasminogen contains 4 to 5 lysine binding sites with low affinity for tranexamic acid (Kd = 750 mol/L) and 1 with high affinity (Kd = 1.1 mol/L). The high affinity lysine site of plasminogen is involved in its binding to fibrin. Saturation of the high affinity binding site with tranexamic acid displaces plasminogen from the surface of fibrin. Although plasmin may be formed by conformational changes in plasminogen, binding to and dissolution of the fibrin matrix is inhibited.

## Structure
- Tranexamic acid is an antifibrinolytic drug. The chemical name is trans-4-aminomethyl-cyclohexanecarboxylic acid. The structural formula is:
- Tranexamic acid is a white crystalline powder. It is freely soluble in water and in glacial acetic acid and is very slightly soluble in ethanol and practically insoluble in ether. The molecular formula is C8H15N02 and the molecular weight is 157.2.
- Tranexamic acid tablets are provided as white oval-shaped tablets and are not scored. Each tablet is debossed with the marking "FP650." The active ingredient in each tablet is 650 mg tranexamic acid. The inactive ingredients contained in each tablet are: microcrystalline cellulose, colloidal silicon dioxide, pregelatinized corn starch, povidone, hypromellose, stearic acid, and magnesium stearate.

## Pharmacodynamics
- Tranexamic acid, at in vitro concentrations of 25 - 100 M, reduces by 20 - 60% the maximal rate of plasmin lysis of fibrin catalyzed by tissue plasminogen activator (tPA).
- Elevated concentrations of endometrial, uterine, and menstrual blood tPA are observed in women with heavy menstrual bleeding (HMB) compared to women with normal menstrual blood loss. The effect of tranexamic acid on lowering endometrial tPA activity and menstrual fluid fibrinolysis is observed in women with HMB receiving tranexamic acid total oral doses of 2-3 g/day for 5 days.
- In healthy subjects, tranexamic acid at blood concentrations less than 10 mg/mL has no effect on the platelet count, the coagulation time or various coagulation factors in whole blood or citrated blood. Tranexamic acid, however, at blood concentrations of 1 and 10 mg/mL prolongs the thrombin time.
Cardiac Electrophysiology
- The effect of tranexamic acid on QT interval was evaluated in a randomized, single-dose, 4-way crossover study in 48 healthy females aged 18 to 49 years. Subjects received (1) tranexamic acid 1300 mg (two 650 mg tablets), (2) tranexamic acid 3900 mg (six 650 mg tablets; three times the recommended single dose), (3) moxifloxacin 400 mg, and (4) placebo. There was no significant increase in the corrected QT interval at any time up to 24 hours after the administration of either dose of tranexamic acid. Moxifloxacin, the active control, was associated with a maximum 14.11 msec mean increase in corrected QT interval (moxifloxacin  placebo) at 3 hours after administration.

## Pharmacokinetics
Absorption
- After a single oral administration of two 650 mg tablets of tranexamic acid, the peak plasma concentration (Cmax) occurred at approximately 3 hours (Tmax). The absolute bioavailability of tranexamic acid in women aged 18-49 is approximately 45%. Following multiple oral doses (two 650 mg tablets three times daily) administration of tranexamic acid for 5 days, the mean Cmax increased by approximately 19% and the mean area under the plasma concentration-time curve (AUC) remained unchanged, compared to a single oral dose administration (two 650 mg tablets). Plasma concentrations reached steady state at the 5th dose of tranexamic acid on Day 2.
- The mean plasma pharmacokinetic parameters of tranexamic acid determined in 19 healthy women following a single (two 650 mg tablets) and multiple (two 650 mg tablets three times daily for 5 days) oral dose of tranexamic acid are shown in Table 3.
Effect of food: tranexamic acid may be administered without regard to meals. A single dose administration (two 650 mg tablets) of tranexamic acid with food increased both Cmax and AUC by 7% and 16%, respectively.
Distribution
- Tranexamic acid is 3% bound to plasma proteins with no apparent binding to albumin. Tranexamic acid is distributed with an initial volume of distribution of 0.18 L/kg and steady-state apparent volume of distribution of 0.39 L/kg.
- Tranexamic acid crosses the placenta. The concentration in cord blood after an intravenous injection of 10 mg/kg to pregnant women is about 30 mg/L, as high as in the maternal blood.
- Tranexamic acid concentration in cerebrospinal fluid is about one tenth of the plasma concentration.
- The drug passes into the aqueous humor of the eye achieving a concentration of approximately one tenth of plasma concentrations.
Metabolism
- A small fraction of the tranexamic acid is metabolized.
Excretion
- Tranexamic acid is eliminated by urinary excretion primarily via glomerular filtration with more than 95% of the dose excreted unchanged. Excretion of tranexamic acid is about 90% at 24 hours after intravenous administration of 10 mg/kg. Most elimination post intravenous administration occurred during the first 10 hours, giving an apparent elimination half-life of approximately 2 hours. The mean terminal half-life of tranexamic acid is approximately 11 hours. Plasma clearance of tranexamic acid is 110-116 mL/min.

### Specific Populations
Pregnancy (Category B)
- Tranexamic acid is not indicated for use in pregnant women. Tranexamic acid is known to cross the placenta and appears in cord blood at concentrations approximately equal to maternal concentration. There are no adequate and well-controlled studies in pregnant women.
Nursing Mothers
- Tranexamic acid is present in the mother's milk at a concentration of about one hundredth of the corresponding serum concentrations. Tranexamic acid should be used during lactation only if clearly needed.
Pediatric Use
- Tranexamic acid is indicated for women of reproductive age and is not intended for use in premenarcheal girls.
- In a randomized, single dose, two-way crossover study of two dose levels (650 mg and 1,300 mg ), pharmacokinetics of tranexamic acid was evaluated in 20 female adolescents (12 to 16 years of age) with heavy menstrual bleeding. The Cmax and AUC values after a single oral dose of 650 mg in the adolescent females were 32  36% less than those after a single oral dose of 1,300 mg in the adolescent females. The Cmax and AUC values after a single oral dose of 1300 mg in the adolescent females were 20  25% less than those in the adult females given the same dose in a separate study.
Geriatric Use
- Tranexamic acid is indicated for women of reproductive age and is not intended for use by postmenopausal women.
Renal Impairment
- The effect of renal impairment on the disposition of tranexamic acid has not been evaluated. Urinary excretion following a single intravenous injection of tranexamic acid declines as renal function decreases. Following a single 10 mg/kg intravenous injection of tranexamic acid in 28 patients, the 24-hour urinary fractions of tranexamic acid with serum creatinine concentrations 1.4  2.8, 2.8  5.7, and greater than 5.7 mg/dL were 51, 39, and 19%, respectively. The 24-hour tranexamic acid plasma concentrations for these patients demonstrated a direct relationship to the degree of renal impairment. Therefore, dose adjustment is needed in patients with renal impairment.
Hepatic Impairment
- The effect of hepatic impairment on the disposition of tranexamic acid has not been evaluated. One percent and 0.5 percent of an oral dose are excreted as a dicarboxylic acid and acetylated metabolite, respectively. Because only a small fraction of the drug is metabolized, no dose adjustment is needed in patients with hepatic impairment.

### Drug Interactions
- No drug-drug interaction studies were conducted with tranexamic acid.
Hormonal Contraceptives
- Because tranexamic acid is antifibrinolytic, concomitant use of hormonal contraception and tranexamic acid may further exacerbate the increased thrombotic risk associated with combination hormonal contraceptives. For this reason, concomitant use of tranexamic acid with combination hormonal contraceptives is contraindicated.
Factor IX Complex Concentrates or Anti-inhibitor Coagulant Concentrates
- Tranexamic acid is not recommended in patients taking either Factor IX complex concentrates or anti-inhibitor coagulant concentrates because the risk of thrombosis may be increased.
Tissue Plasminogen Activators
- Concomitant therapy with tissue plasminogen activators may decrease the efficacy of both tranexamic acid and tissue plasminogen activators. Therefore, exercise caution if a patient taking tranexamic acid therapy requires tissue plasminogen activators.
All-Trans Retinoic Acid (Oral Tretinoin)
- In a study involving 28 patients with acute promyelocytic leukemia who were given either orally administered all-trans retinoic acid plus intravenously administered tranexamic acid, all-trans retinoic acid plus chemotherapy, or all-trans retinoic acid plus tranexamic acid plus chemotherapy, all 4 patients who were given all-trans retinoic acid plus tranexamic acid died, with 3 of the 4 deaths due to thrombotic complications. It appears that the procoagulant effect of all-trans retinoic acid may be exacerbated by concomitant use of tranexamic acid. Therefore, exercise caution when prescribing tranexamic acid to patients with acute promyelocytic leukemia taking all-trans retinoic acid.

## Nonclinical Toxicology

### Carcinogenesis, Mutagenesis, Impairment of Fertility
- Carcinogenesis
- Carcinogenicity studies with tranexamic acid in male mice at doses as high as 6 times the recommended human dose of 3900 mg/day showed an increased incidence of leukemia which may have been related to treatment. Female mice were not included in this experiment.
- The dose multiple referenced above is based on body surface area (mg/m2). Actual daily dose in mice was up to 5000 mg/kg/day in food.
- Hyperplasia of the biliary tract and cholangioma and adenocarcinoma of the intrahepatic biliary system have been reported in one strain of rats after dietary administration of doses exceeding the maximum tolerated dose for 22 months. Hyperplastic, but not neoplastic, lesions were reported at lower doses. Subsequent long-term dietary administration studies in a different strain of rat, each with an exposure level equal to the maximum level employed in the earlier experiment, have failed to show such hyperplastic/neoplastic changes in the liver.
- Mutagenesis
- Tranexamic acid was neither mutagenic nor clastogenic in the in vitro Bacterial Reverse Mutation Assay (Ames test), in vitro chromosome aberration test in Chinese hamster cells, and in in vivo chromosome aberration tests in mice and rats.
- Impairment of Fertility
- Reproductive studies performed in mice, rats and rabbits have not revealed any evidence of impaired fertility or adverse effects on the fetus due to tranexamic acid.
- In a rat embryo-fetal developmental toxicity study, tranexamic acid had no adverse effects on embryo-fetal development when administered during the period of organogenesis (from gestation days 6 through 17) at doses 1, 2 and 4 times the recommended human oral dose of 3900 mg/day. In a perinatal-postnatal study in rats, tranexamic acid had no adverse effects on pup viability, growth or development when administered from gestation day 6 through postnatal day 20 at doses 1, 2 and 4 times the recommended human oral dose of 3900 mg/day.
- The dose multiples referenced above are based on body surface area (mg/m2). Actual daily doses in rats were 300, 750 or 1500 mg/kg/day.

### Animal Toxicology and/or Pharmacology
- Ocular Effects
- In a 9-month toxicology study, dogs were administered tranexamic acid in food at doses of 0, 200, 600, or 1200 mg/kg/day. These doses are approximately 2, 5, and 6 times, respectively, the recommended human oral dose of 3900 mg/day based on AUC. At 6 times the human dose, some dogs developed reversible reddening and gelatinous discharge from the eyes. Ophthalmologic examination revealed reversible changes in the nictitating membrane/conjunctiva. In some female dogs, the presence of inflammatory exudate over the bulbar conjunctival mucosa was observed. Histopathological examinations did not reveal any retinal alteration. No adverse effects were observed at 5 times the human dose.
- In other studies, focal areas of retinal degeneration were observed in cats, dogs and rats following oral or intravenous tranexamic acid doses at 6-40 times the recommended usual human dose based on mg/m2 (actual animal doses between 250-1600 mg/kg/day).

# Clinical Studies
- The efficacy and safety of tranexamic acid in the treatment of heavy menstrual bleeding (HMB) was demonstrated in one 3-cycle treatment and one 6-cycle treatment, randomized, double-blind, placebo-controlled study. In these studies, HMB was defined as an average menstrual blood loss of  80 mL as assessed by alkaline hematin analysis of collected sanitary products over two baseline menstrual cycles. Subjects were 18 to 49 years of age with a mean age of approximately 40 years, had cyclic menses every 21-35 days, and a BMI of approximately 32 kg/m2. On average, subjects had an HMB history of 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.
- In these studies, the primary outcome measure was menstrual blood loss (MBL), measured using the alkaline hematin method. The endpoint was change from baseline in MBL, calculated by subtracting the mean MBL during treatment from the mean pretreatment MBL.
- The key secondary outcome measures were based on specific questions concerning limitations in social or leisure activities (LSLA) and limitations in physical activities (LPA). Large stains (soiling beyond the undergarment) were also included as a key secondary outcome measure.

## Three-Cycle Treatment Study
- This 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 on MBL over a 3-cycle treatment duration. Of the 294 evaluable subjects, 115 tranexamic acid 1950 mg/day subjects, 112 tranexamic acid 3900 mg/day subjects and 67 placebo subjects took at least one dose of study drug and had post-treatment data available.
- Results are shown in Table 4. MBL was statistically significantly reduced in patients treated with 3900 mg/day tranexamic acid compared to placebo. Study success also required achieving a reduction in MBL that was determined to be clinically meaningful to the subjects. The 1950 mg/day tranexamic acid dose did not meet the criteria for success.
- Tranexamic acid also statistically significantly reduced limitations on social, leisure, and physical activities in the 3900 mg/day dose group compared to placebo (see TABLE 5). No statistically significant treatment difference was observed in response rates on the number of large stains.

## Six-Cycle Treatment Study
- This study compared the effects of tranexamic acid 3900 mg/day given daily for up to 5 days during each menstrual period versus placebo on MBL over a 6-cycle treatment duration. Of the 187 evaluable subjects, 115 tranexamic acid subjects and 72 placebo subjects took at least one dose of study drug and had post-treatment data available.
- Results are shown in Table 6. MBL was statistically significantly reduced in patients treated with 3900 mg/day tranexamic acid compared to placebo. Study success also required achieving a reduction in MBL that was determined to be clinically meaningful to the subjects.
- Limitations on social, leisure, and physical activities were also statistically significantly reduced in the tranexamic acid group compared to placebo (see TABLE 7). No statistically significant treatment difference was observed in response rates on the number of large stains.

## MBL Results over Time
- The efficacy of tranexamic acid 3900 mg/day over 3 menstrual cycles and over 6 menstrual cycles was demonstrated versus placebo in the double-blind, placebo-controlled efficacy studies (see FIGURE 1). The change in MBL from baseline was similar across all post-baseline treatment cycles.
- Figure 1: MBL Levels over Duration of Therapy

# How Supplied
- Tranexamic acid tablets are provided as white oval-shaped tablets. Each tablet is debossed with the marking "FP650" and are supplied as:

## Storage
- Store at room temperature 25 C (77 F); excursions permitted to 15-30 C (59-86 F). .

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- See FDA-APPROVED PATIENT LABELING (PATIENT INFORMATION)
- Instruct patients that the usual schedule is to take two tablets with liquids, three times a day during menstruation. Patients should be instructed not to exceed 3 doses (6 tablets) in a 24-hour period or to take for more than 5 days in any menstrual cycle.
- Inform patients that they should immediately stop LYSTEDA if they notice any eye symptoms or change in their vision. Instruct them to report any such problems promptly to their physician and to follow-up with an ophthalmologist for a complete ophthalmic evaluation, including dilated retinal examination of the retina.
- Inform patients that they should stop LYSTEDA and seek immediate medical attention if they notice symptoms of a severe allergic reaction (e.g., shortness of breath or throat tightening).
- Instruct patients that common side effects of LYSTEDA include headache, sinus and nasal symptoms, back pain, abdominal pain, musculoskeletal pain, joint pain, muscle cramps, migraine, anemia and fatigue.
- Advise patients to contact their healthcare provider if their heavy menstrual bleeding symptoms persist or worsen.
- Remind patients to read the Patient Labeling carefully.

# Precautions with Alcohol
Alcohol-Tranexamic acid (oral) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- LYSTEDA

# Look-Alike Drug Names
- There is limited information regarding Look-Alike Drug Names.

# Drug Shortage Status

# Price