Pharmacokinetic Studies in Women of 2 Novel Oral Formulations of Tranexamic Acid Therapy for Heavy Menstrual Bleeding

WOMAN-PharmacoTXA trial: Study protocol for a randomised controlled trial to assess the pharmacokinetics and pharmacodynamics of intramuscular, intravenous and oral administration of tranexamic acid in women giving birth by caesarean section

Background: Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH). Most PPH deaths occur in the first hours after giving birth and treatment delay decreases survival.  One barrier to rapid TXA treatment is the need for intravenous injection. Intramuscular injection and oral solution of TXA would be easier and faster to administer and would require less training. However, the pharmacokinetics (PK), pharmacodynamics and safety of TXA administered by different routes in pregnant women have not been established. The main aim of this study is to ascertain whether IM and oral solution of TXA will be absorbed at levels sufficient to inhibit fibrinolysis in pregnant women.

Methods: WOMAN-PharmacoTXA is a prospective, randomised, open label trial to be conducted in Zambia and Pakistan.  Adult women undergoing caesarean section with at least one risk factor for PPH will be included.  Women will be randomised to receive one of the following about 1 hour prior to caesarean section: 1-gram TXA IV, 1-gram TXA IM, 4-grams TXA oral solution or no TXA. Randomisation will continue until 120 participants with at least six post randomisation PK samples are included. TXA concentration in maternal blood samples will be measured at baseline and at different time points during 24 hours after receipt of intervention. Blood TXA concentration will be measured from the umbilical cord and neonate.

The primary endpoint is maternal blood TXA concentrations over time. Secondary outcomes include umbilical cord and neonate TXA concentration D-dimer concentration, blood loss and clinical diagnosis of PPH, injection site reactions and maternal and neonate adverse events.

Discussion: The WOMAN-PharmacoTXA trial will provide important data on pharmacokinetics, pharmacodynamics and safety of TXA after IV, intramuscular and oral administration in women giving birth by caesarean section.

Trial registration: ClincalTrials.gov, NCT04274335 (18/02/2020).

Plasma Concentrations of Tranexamic Acid in Postpartum Women After Oral Administration

OBJECTIVE

To evaluate the pharmacokinetics of tranexamic acid after oral administration to postpartum women.

METHODS

We conducted a single-center pharmacokinetic study at Teaching Hospital-Jaffna, Sri Lanka, on 12 healthy postpartum women who delivered vaginally. After oral administration of 2 g of immediate-release tranexamic acid 1 hour after delivery, pharmacokinetic parameters were measured on plasma samples at 0, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 10, and 12 hours. Plasma tranexamic acid concentrations were determined by high-performance liquid chromatography. The outcome measures were maximum observed plasma concentration, time to maximum plasma concentration, time to reach effective plasma concentration, time period effective serum concentration lasted, area under the curve for drug concentration, and half-life of tranexamic acid.

RESULTS

The mean maximum observed plasma concentration was 10.06 micrograms/mL (range 8.56-12.22 micrograms/mL). The mean time to maximum plasma concentration was 2.92 hours (range 2.5-3.5 hours). Mean time taken to reach the effective plasma concentration of 5 micrograms/mL and the mean time this concentration lasted were 0.87 hours and 6.73 hours, respectively. Duration for which plasma tranexamic acid concentration remained greater than 5 micrograms/mL was 5.86 hours. Half-life was 1.65 hours. Area under the curve for drug concentration was 49.16 micrograms.h/mL (range 43.75-52.69 micrograms.h/mL).

CONCLUSION

Clinically effective plasma concentrations of tranexamic acid in postpartum women may be achieved within 1 hour of oral administration. Given the promising pharmacokinetic properties, we recommend additional studies with larger sample sizes to investigate the potential of oral tranexamic acid for the treatment or prophylaxis of postpartum hemorrhage.

Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents

IMPORTANCE

Heavy menstrual bleeding is a common cause of anemia and reduced quality of life in adolescents. There is a higher prevalence of bleeding disorders in girls with heavy menstrual bleeding than in the general population. Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care.

OBSERVATIONS

The most common cause of heavy menstrual bleeding in adolescents is ovulatory dysfunction, followed by coagulopathies. The most common inherited bleeding disorder is von Willebrand disease, and its incidence in adolescents with heavy menstrual bleeding is high. Distinguishing the etiology of heavy menstrual bleeding will guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. Among hormonal agents, the 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders.

CONCLUSIONS AND RELEVANCE

Anemia, need for transfusion of blood products, and hospitalization may be avoided with prompt recognition, diagnosis, and treatment of heavy menstrual bleeding, especially when in the setting of bleeding disorders. Safe and effective treatment methods are available and can greatly improve quality of life for affected adolescents. A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal.

Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding

Unpredictable, prolonged or heavy menstrual bleeding (HMB) may be expected for many adolescents soon after menarche. A decade of clinical experience and research has now established firmly that bleeding disorders (BD) are common in adolescents with HMB. Despite these advances, many questions remain, and several aspects of the diagnosis and management of BDs in adolescents are not supported by rigorous clinical trials. In this overview, four major areas will be discussed. First, we will discuss the frequency of BDs in young women with HMB. Up to 20% of older females with HMB are thought to have an underlying BD. Estimates from retrospective studies in adolescents suggest a prevalence that varies anywhere from 10 to 62%. Prospective studies with uniform hemostatic evaluation are needed to answer this question definitively. Second, we will review existing tools that help screen and diagnose adolescents with HMB with an underlying BD. Although identification of an underlying BD in older women with HMB is relatively straight forward, uncertainties remain for adolescents. Heavy menstrual bleeding in this age group may have different pathophysiological underpinnings than those in older women and may often be disregarded as anovulatory. There is an urgent need to develop novel tools, and evaluate existing diagnostic strategies in adolescents. Third, we will discuss the optimal medical management of HMB in young adolescents. As direct evidence is largely lacking, these areas are also subject to extrapolation from older women. Lastly, an important area- prediction, and management of future bleeding in those adolescents who are diagnosed with a mild BD-will be discussed. Throughout, areas of controversy and opportunities for further research are highlighted.

Efficacy and safety of oral tranexamic acid in women with heavy menstrual bleeding and fibroids

AIM

To evaluate the efficacy and safety of oral, modified-release tranexamic acid in women with heavy menstrual bleeding and fibroids.

MATERIALS & METHODS

This was a pooled analysis of two pivotal Phase III studies. Fibroids were evaluated by transvaginal ultrasonography. Menstrual blood loss (MBL) was measured via a validated alkaline hematin method.

RESULTS

In women with and without fibroids, mean MBL was reduced compared with placebo across all treatment cycles (p < 0.001). Within the tranexamic acid group, more statistically significant (p < 0.001) reductions in MBL compared with placebo occurred in women with fibroids than in those without fibroids. Adverse events were similar between treatment groups.

CONCLUSION

Tranexamic acid was well tolerated and reduced MBL in women with and without fibroids.

Medical treatment of idiopathic heavy menstrual bleeding. What is new? An evidence based approach

BACKGROUND

Heavy menstrual bleeding (HMB) is an important health problem affecting up to 30 % of reproductive age women, interfering with their quality of life. Medical therapy, with the avoidance of unnecessary surgery, is an attractive option.

PURPOSE

To provide a comprehensive review of the current medical treatments available for idiopathic HMB and to focus on the newly introduced modalities. Furthermore, to provide a practical algorithm based on the best available evidence.

METHODS

A PubMed search was conducted looking for the different trials, reviews and various guidelines relating to medical treatment of idiopathic HMB.

RESULTS

The most effective medical treatment for idiopathic HMB is the levonorgestrel-releasing intrauterine system. It provides a reliable long-term effect. Importantly, there is a growing scientific evidence for new modalities entailing; modified-release formulation of tranexamic acid, the new four-phasic estradiol valerate/dienogest contraceptive pills and combined contraceptive vaginal ring. Also, vaginal danazol has been tried.

CONCLUSION

Maintenance of status quo, i.e., keeping first-line treatment of idiopathic HMB as medical treatment is an essential issue. Modified-release formulation of tranexamic acid, the new four-phasic contraceptive pills and contraceptive vaginal ring are recently added to the medical armamentarium for treatment of idiopathic HMB increasing its efficacy.

Daily Menstrual Blood Loss and Quality of Life in Women with Heavy Menstrual Bleeding

Aim: Excessive blood loss during menstruation is a major problem for women of reproductive age. Women who experience heavy menstrual bleeding (HMB) often present to physicians because of the subsequent negative impact HMB has on their daily lives and activities. The objective of this post-hoc analysis is to evaluate daily menstrual blood loss (MBL) in women with HMB and assess the relationship between daily MBL and women's perceptions of MBL, limitations in physical activities and limitations in social/leisure activities as measured by the Menorrhagia Impact Questionnaire. Materials & methods: Data from two randomized, placebo-controlled studies of an oral tranexamic acid formulation in women with HMB were assessed. Daily MBLs and Menorrhagia Impact Questionnaire scores were evaluated for two pretreatment cycles and the first three tranexamic acid treatment cycles of each study. Effect-size analyses were not conducted. Results & conclusion: Highest daily MBLs occurred on days 2 and 3 of menstrual cycles. Women's perceptions of daily MBL were consistent with objective measures of MBL. Higher daily MBL was related to increased limitations in physical activities and limitations in social/leisure activities. Daily MBL values were consistent with women's perceptions of MBL. Reduced daily MBL was associated with improvements in health-related quality of life.

Oral Modified-Release Tranexamic Acid for Heavy Menstrual Bleeding

OBJECTIVE:

To review the pharmacology, pharmacokinetics, efficacy, and safety profile of an oral modified-release (MR) formulation of tranexamic acid.

DATA SOURCES:

Literature was accessed through MEDLINE (1966-July 2012), Iowa Drug Information Service (1997-July 2012), and bibliographies of pertinent articles. Search terms included tranexamic acid, Lysteda, menorrhagia, menstrual blood loss, and heavy menstrual bleeding.

STUDY SELECTION AND DATA EXTRACTION:

All available English-language abstracts and human studies were identified for review. Data provided by the manufacturer and the Food and Drug Administration were also evaluated. Efficacy was evaluated in 2 clinical trials, change in quality of life was evaluated in 3 clinical trials, and safety was evaluated in 4 clinical trials.

DATA SYNTHESIS:

Tranexamic acid is a synthetic lysine analogue with antifibrinolytic activity. It interferes with the binding of plasminogen to fibrin, resulting in enhanced fibrin clot integrity. A novel MR formulation of oral tranexamic acid is approved for treatment of cyclic heavy menstrual bleeding. MR tranexamic acid is initiated at the beginning of heavy menstrual bleeding and can be taken for up to 5 days per cycle. Clinical trials show it to be safe and effective. Dosage adjustments are needed for women with renal insufficiency. Adverse effects are considered mild to moderate, with the most common being menstrual discomfort, headache, and back pain. The most significant safety concerns relate to the risk of thromboembolism.

CONCLUSIONS:

MR tranexamic acid offers a new first-line therapy for patients with cyclic heavy menstrual bleeding. It is reported to be safe and effective. There are no labeled equivalents to MR tranexamic acid for cyclic heavy menstrual bleeding.