Disorders of coagulation or thrombosis - use of antifibrinolytic agents

Agents

Antifibrinolytics inhibit clot breakdown - adjuncts to reduce bleeding, not anticoagulants/procoagulants
Tranexamic acid (TXA) - lysine analogue, blocks plasminogen binding to fibrin -> inhibits plasmin-mediated fibrinolysis
Aminocaproic acid - same class, less commonly used (Australia)

Trauma, major surgery, postpartum haemorrhage -> hyperfibrinolysis contributes to ongoing bleeding
TXA competitively blocks lysine-binding sites on plasminogen -> prevents its activation to plasmin -> stabilises formed clot
Does not treat the underlying cause of bleeding - adjunct only

Clinical context, not a diagnostic test in itself
ROTEM/TEG - can demonstrate hyperfibrinolysis (shortened lysis time) supporting use in complex bleeding (trauma, cardiac surgery, liver disease)

Major trauma with significant haemorrhage - TXA 1g IV bolus then 1g over 8h, within 3 hours of injury (CRASH-2/CRASH-3) - benefit lost/potentially harmful if given later
Postpartum haemorrhage - TXA 1g IV, repeat once if bleeding continues, as early as possible (WOMAN trial)
Menorrhagia - oral TXA during menses
Cardiac surgery - reduces blood loss/transfusion requirement, routine in many protocols
Hereditary bleeding disorders (haemophilia, mild vWD) - adjunct for mucosal bleeding/minor procedures (dental extraction), alongside factor replacement/desmopressin
Hereditary angioedema - alternative prophylaxis where C1-inhibitor unavailable

Active or high risk of thrombosis (recent VTE, arterial thrombosis) - relative/absolute depending on severity
Haematuria from upper urinary tract - risk of ureteric clot colic/obstruction
Renal impairment - dose reduction (renally cleared)
CNS bleeding - evidence more nuanced (some trauma/ICH benefit shown, seizure risk at high doses)

Used alongside, not instead of, definitive haemostatic management (surgery, factor replacement, uterotonics)
Distinguish from procoagulants (prothrombinex, FFP, factor concentrates) - different mechanism, different indications

Seizures - dose-related risk, esp. high-dose cardiac surgery use or renal impairment
Thrombotic events - theoretical concern, not clearly demonstrated as increased in major trials (CRASH-2/3, WOMAN) at standard doses
Visual disturbance - rare, reported with prolonged use

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