Tranexamic Acid vs. Amicar

** Updated June 2022**

Over the years, our hospital has been using Amicar… until there was a drug shortage.  With that drug shortage came a different drug called tranexamic acid.  We’ve been using it for awhile and I can’t seem to tell a difference in coagulation between the two drugs.  Let’s break down each one and also discuss cost-effectiveness.

Amicar

What is it?


From MedPage Today

Tranexamic Acid

What is it?

Tranexamic acid acts by reversibly blocking the lysine binding sites of plasminogen, thus preventing plasmin activation and, as a result, the lysis of polymerised fibrin.12 Tranexamic acid is frequently utilised to enhance haemostasis, particularly when fibrinolysis contributes to bleeding. In clinical practice, tranexamic acid has been used to treat menorrhagia, trauma-associated bleeding and to prevent perioperative bleeding associated with orthopaedic and cardiac surgery.13–16 Importantly, the use of tranexamic acid is not without adverse effects. Tranexamic acid has been associated with seizures,17 18 as well as concerns of possible increased thromboembolic events, including stroke which to date have not been demonstrated in randomised controlled trials.

Fibrinolysis is the mechanism of clot breakdown and involves a cascade of interactions between zymogens and enzymes that act in concert with clot formation to maintain blood flow.25 During extracorporeal circulation, such as cardiopulmonary bypass used in cardiac surgery, multiplex changes in haemostasis arise that include accelerated thrombin generation, platelet dysfunction and enhanced fibrinolysis.26 Tranexamic acid inhibits fibrinolysis, a putative mechanism of bleeding after cardiopulmonary bypass, by forming a reversible complex with plasminogen.

Dosing:

  • Ortho/Spine
  • OB
  • Trauma

Currently at our hospital (June 2022):

TXA DOSING AND ADMINISTRATION OVERVIEW

How supplied from PharmacyTXA 1000mg/10mL vials Will not provide premade bags like with Amicar; Amicar is a more complex mixture than TXA Will take feedback on this after go-live and reassess
Where it will be supplied from PharmacyPOR-SUR1 Omnicell (in HeartCore Room)   Perfusion Tray (will replace aminocaproic acid vials 6/7)  
Recommended Dosing (see below for evidence)~20 mg/kg total dose Can give as: 20 mg/kg x 1, OR 10 mg/kg x 1, followed by 1-2 mg/kg/h*   Perfusion may also prime bypass solution with 2 mg/kg x 1*
Preparation & AdministrationIV push straight drug (1000mg/10mL) from vial   AND/OR   Mix vial of 1000mg/10mL TXA with 250mL NS for continuous infusion*

TXA & Amicar ADRs

  • Seizure risk may be increased also by duration of prolonged open-chamber surgery based on findings from Zuffery, et al. Anesthesiology 2021.
  • Per OR pharmacist at Scripps Mercy, they have not seen an increased incidence of seizures in their patient-population (anecdotally)

DOSING EVIDENCE

There are a number of dosing strategies in the literature. What I recommend for maximal safety and efficacy is taken from Zuffery, et al. Anesthesiology 2021 meta-analysis and is practiced at Scripps Mercy.

  • ~ 20 mg/kg total dose recommended in this meta-analysis.
  • Two dosing strategies they report that were as effective as high-dose but with lower seizure risk than high dose:

Author: Kris

Grew up in a small Texas town. Heavily involved in extracurricular activities: piano, violin, dance (ballet/jazz/tap), tennis, horseback riding (english/western), taekwondo, basketball, soccer, volleyball, percussion, drumline, orchestra, band, mascot, pageants. I had the typical Tiger Mom upbringing. Went to college, medical school, residency, and fellowship. Amidst the ups and downs of life, allow me to share with you my journey...as an "ordinary" person who happens to be an MD.

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