In this episode, I’ll discuss the role for tranexamic acid in the treatment of epistaxis.
Tranexamic acid is an antifibrinolytic agent. It works by forming a reversible complex that displaces plasminogen from fibrin. This results in the inhibition of fibrinolysis.
Tranexamic acid has been used in oral or topical form in addition to standard therapy as an adjunct in the treatment of epistaxis.
Published evidence has not consistently identified a benefit to the use of tranexamic acid in the setting of epistaxis. Therefore, a recent Cochrane review sought to determine the effects of tranexamic acid in the management of patients with epistaxis.
The reviewers were able to identify 6 randomized controlled trials for inclusion using the Cochrane methodology. Two of these trials used oral tranexamic acid and four used topical application of tranexamic acid.
For the primary outcome of re-bleeding within a period of up to 10 days, tranexamic acid had a statistically significant effect vs placebo with a risk ratio of 0.71. Topical application of tranexamic acid had a non-significant trend toward a slightly more favorable risk ratio compared with oral tranexamic acid.
In addition, pooled data from 3 of the studies showed a risk ratio of 2.35 for stoppage of bleeding within 10 minutes in favor of topical tranexamic acid.
A review published in Academic Emergency Medicine points out some weaknesses of the Cochrane review including:
- There was significant clinical heterogeneity in the studies examined with different routes of administration, different comparators (active vs placebo), and different study outcomes.
- Adverse event reporting was poor.
- Half of the trials did not assess the location of the bleeding (anterior vs posterior).
The Academic Emergency Medicine authors stated:
Despite inconsistent reporting of adverse events, the occurrence of such events appear s to be unlikely, particularly with topical use. Therefore, we have assigned a color recommendation of Green (Benefit > Harm) to the use of TXA for epistaxis
A common technique to implement topical tranexamic acid is to saturate a nasal tampon used for packing with 5 mL of 100mg/mL tranexamic acid IV solution just prior to the packing procedure.
This technique is likely only applicable to anterior bleeds as posterior bleeding is treated by balloon catheters instead of cotton packing. However, some posterior bleeding treatments include both a balloon catheter and an anterior packing that would absorb topical tranexamic acid.
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