トラネキサム酸

今週のNEJMに帝王切開時のトラネキサム酸投与による出血予防に関するStudyが載ってたので簡単なまとめUptodateより

 

トラネキサム酸が出血量を抑えるのに有効な疾患

月経過多

子宮出血

帝王切開

外傷による出血(受傷から3時間以内がよい適応)

von Willebrand病患者の出血、や出血が見込まれる手術前

心血管手術(バイパス前)

頭部外傷:GCSが8-13の中等度のTBI患者では投与推奨

Tranexamic acid 1 g is infused over 10 minutes, followed by an intravenous (IV) infusion of 1 g over eight hours.

 

 

トラネキサム酸投与が有効でない疾患(有効性が示されていない疾患)

上部消化管出血

鼻出血

脳出血

 

 

抗凝固療法中患者の歯科処置

5-10分前にトラネキサム酸の5%製剤で口腔内をゆすぐ。

2分ほどその状態を保つ。

処置後1時間は飲食禁止

処置後1-2日は1日に3-4回上記の口腔内処置を行う

(ACCP [Douketis 2012]; Borea 1993; Gaspar 1997; Lam 2011; Patatanian 2006).

 

喀血患者に対して

トラネキサム酸500mgを溶かした生食を1日3回吸入

(Segrelles 2016; Wand 2018).

 

遺伝性毛細血管拡張症患者の出血予防

use of 500 mg tablets available internationally, but not in the United States.

トラネキサム酸を1日1.0-1.5g内服(分2-3)。出血があまり起こらないようなら0.5-1.0gに減量してもよい

(Gompels 2005; Levy 2010); maximum total daily dose: 4 to 6 g/day (Bowen 2010; WAO/EEACI [Maurer 2018]).

 

遺伝性毛細血管拡張症患者の鼻出血など出血に対して

1日3.0gになるよう分2-3で4-10日間内服

経過によって2.0-4.5gに内服量を変更

(Gaillard 2014; Geisthoff 2014; Pabinger 2017).

 

 

Intracranial hemorrhage associated with thrombolytic treatment (alternative therapy) (off-label use):

抗血栓治療を行った脳出血患者でクリオプレシピテート使用した場合に追加でトラネキサム酸投与を考慮

(NCS/SCCM [Frontera 2016]).

1g(10-15mg/kg)を100mg/minを越えない速さで投与

(AHA/ASA [Powers 2018]; NCS/SCCM [Frontera 2016]).

 

重度の月経

ホルモン療法が行えない場合に

Lysteda: 1.3 g three times daily for up to 5 days during monthly menstruation.

Cyklokapron [Canadian product]: 1 to 1.5 g three to four times daily for several days during menstruation.

 

心臓手術などかなりの出血が見込まれる場合、出血予防として使用を考慮

IV: 1 g (or 10 to 30 mg/kg) を処置(手術前に);10-30分かけて投与

処置の種類によっては持続投与を考慮する

 

心臓手術

IV: Loading dose: 10 to 30 mg/kg administered at a rate not to exceed 100 mg/minute (generally over 10 to 20 minutes), followed by 1 to 16 mg/kg/hour (Fergusson 2008; Nuttall 2008; Sigaut 2014). Alternatively, some centers administer a single loading dose of 50 mg/kg (Myles 2017).

 

整形外科手術 Major surgery

Note: Optimal regimen is uncertain; refer to institutional protocol. Use in patients without a baseline high risk of thromboembolism. For patients with risk factors for thromboembolism, consider risk of thromboembolism vs benefit of reduced blood loss (Amundson 2020).

 

IV: 1 g (or 10 to 15 mg/kg) administered before skin incision at a rate not to exceed 100 mg/minute (generally over 10 to 20 minutes); repeat dose at skin closure or up to 12 hours later; some experts recommend a third dose during the postoperative period if needed (AAHKS/ASRA/AAOS [Fillingham 2018b]; Erens 2019; Kim 2014; MacGillivray 2011; Maniar 2012; Martin 2020; Xiao 2019; Zufferey 2010). Note: Some experts use intra-articular tranexamic acid (ie, 1 g per 50 mL of NS applied topically into the wound at the end of the procedure) (AAHKS/ASRA/AAOS [Fillingham 2018b]; Alshryda 2013a; Alshryda 2013b).

 

脊椎手術

IV: 10 to 15 mg/kg administered prior to incision at a rate not to exceed 100 mg/minute (generally over 10 to 20 minutes), followed by 1 to 2 mg/kg/hour as a continuous infusion for the remainder of the surgery; discontinue at the end of the procedure (Brown 2019; Lu 2018; Wong 2008).

 

 

産後出血

IV: 1 g over 10 to 20 minutes (Berghella 2021; Saccone 2019); some experts administer before skin incision for cesarean deliveries and after cord clamping for vaginal deliveries (Berghella 2021).

 

Postpartum hemorrhage, treatment (off-label use):

 

Note: For continued bleeding despite oxytocin; used in conjunction with other therapies/procedures.

 

IV: 1 g over 10 to 20 minutes given within 3 hours of vaginal birth or cesarean delivery. If bleeding continues after 30 minutes, may repeat the dose in conjunction with thorough re-evaluation for cause of continued or recurrent bleeding (WOMAN Trial Collaborators 2017).

 

 

くも膜下出血、動脈瘤再破裂予防

Note: Routine early use prior to aneurysm repair is not recommended (Post 2021). Optimal regimen has not been established; refer to institutional protocol.

 

IV: 1 g over 10 minutes immediately after diagnosis, followed by 1 g every 6 hours for no more than 72 hours (Hillman 2002).

 

出血傾向のある患者の歯科処置

Note: Generally used in conjunction with (and not as a substitute for) replacement of the appropriate clotting factor, especially in individuals with hemophilia. Do not give simultaneously with an activated prothrombin complex concentrate, as this can increase the risk of thromboembolism; if used concurrently, they should be separated by ≥12 hours (WFH [Srivastava 2013]). Consultation with a hemophilia treatment center is advised.

 

IV: 10 mg/kg using actual body weight (usual dose range: 500 mg to 1 g) administered ~2 hours before procedure at a rate not to exceed 100 mg/minute (generally over 10 to 20 minutes), then 10 mg/kg 3 to 4 times daily for 2 to 8 days. Alternatively, 10 mg/kg as a single dose ~2 hours prior to procedure; following procedure, transition to oral tranexamic acid depending on individual patient characteristics, type of procedure, other therapies, and degree of bleeding (Berube 2020; Cyklokapron Canadian product monograph; van Galen 2019).

 

Oral: 25 mg/kg (usual dose range: 1 to 1.5 g) given 2 hours prior to procedure, then 25 mg/kg (usual dose range: 1 to 1.5 g) 3 to 4 times daily for up to 7 to 10 days (Berube 2020; Cyklokapron Canadian product monograph; Hoots 2021; van Galen 2019). The recommended oral dosage range is based on use of 500 mg tablets available internationally, but not in the United States.

 

 

外傷性出血、TBI

Note: Consider for use in patients with significant hemorrhage, at risk of significant hemorrhage, or in moderate traumatic brain injury (TBI) (Glasgow Coma Scale [GCS] score >8 and <13); patients with severe TBI (GCS score 3 to 8) may not demonstrate benefit (CRASH-2 Trial Collaborators 2010; CRASH-3 Trial Collaborators 2019; Rajajee 2020).

 

IV: Loading dose: 1 g over 10 minutes started within 3 hours of injury, followed by 1 g over the next 8 hours as a continuous infusion. Note: Some experts suggest using thromboelastogram or rotational thromboelastometry to guide repeat dosing (Callum 2019; CRASH-2 Trial Collaborators 2010; CRASH-2 Trial Collaborators 2011; CRASH-3 Trial Collaborators 2019; Galvagno 2019).