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Inhaled Tranexamic Acid for Hemoptysis?

November 19, 2018

Written by Sam Parnell

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For patients with hemoptysis, inhaled tranexamic acid was associated with significantly reduced expectorated blood volume, hospital length of stay, need for invasive interventions, and hemoptysis recurrence rate at one year. Patients with inhaled tranexamic acid also had higher rate of hemoptysis resolution within 5 days.

Why does this matter?
Hemoptysis, defined as the expectoration of blood, has a broad differential and can range from simple blood streaked sputum to life-threatening massive hemoptysis. Management of hemoptysis consists of interventional procedures to stop hemorrhage along with identifying and treating the specific underlying cause. However, there are few other effective medical therapies for undifferentiated hemoptysis besides supportive care. Intravenous tranexamic acid (TXA) has shown promise at reducing surgical blood loss, decreasing abnormal uterine bleeding, and controlling acute hemorrhage in trauma. Therefore, could inhaled TXA be a potential medical therapy for hemoptysis?

TXA in hemoptysis: The results may take your breath away…
This was a single center, prospective, double-blind, randomized, placebo-controlled trial of 47 adults with hemoptysis comparing nebulized TXA 500 mg/5 ml vs nebulized normal saline 5 ml as the placebo control, given 3 times a day up to 5 days from admission. Patients with massive hemoptysis (expectorated blood > 200 ml/24 hrs), respiratory or hemodynamic compromise, pregnancy, renal or hepatic failure, coagulopathy, or TXA hypersensitivity were excluded.

TXA compared to placebo was associated with an improved rate of hemoptysis resolution within 5 days (96% vs 50%, p<0.0005), reduced length of stay (5.7 vs 7.8 days, p=0.046), reduced rate of invasive procedures such as bronchoscopy or angiographic embolization (0% vs 18.2%, p=0.041), and reduced recurrence of hemoptysis at 1 year (4% vs 22.7%, p=0.0092). No side effects were noted.

This was a small single center study with several limitations and a large proportion of patients excluded that we normally care for in the Emergency Department, including those with massive hemoptysis. However, the results are compelling that nebulized tranexamic acid may be a safe and effective treatment option for patients with hemoptysis. With little downside and few other proven medical therapies for hemoptysis, nebulized TXA could be a useful adjunct to add to your mental tool belt.

Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Oct 12. pii: S0012-3692(18)32572-8. doi: 10.1016/j.chest.2018.09.026. [Epub ahead of print]

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Reviewed by Clay Smith

4 thoughts on “Inhaled Tranexamic Acid for Hemoptysis?

  • What was the randomization method and type? How was allocation concealment achieved? What is the attrition rate, if any, and what were the numbers analyzed? There are many critical details missing in this report.

    • If you are an email subscriber, just reply and it comes to me. It’s considered fair use to share an article with a colleague for educational purposes. I am happy to send you the full text. That way you can get all these details. We try to keep JF brief and include only the most salient features. It is a different niche than a site like The Bottom Line, for example.

  • I’m a 43 year old woman and I’ve been experiencing reccurent episodes of mild/moderate hemoptysis since July 14th, 2019. It’s now August 21st, 2019 and no cause has been found. I’ve received 4 units of blood to date. The same thing happened to me at age 17 and I was diagnosed with Idiopathic Pulmonary Hemosiderosis. I was given high dose Prednisone wich resolved the hemoptysis but sent me into a crippling depression and caused massive weight gain. How can I convince a Doctor to let me try Nebulized Tranexamic Acid instead of Prednisone?

    • I am so sorry to hear that you are having trouble. Patients with massive hemoptysis were excluded from this study, which makes it hard to know how to apply it in your situation. It sounds like an honest, open discussion of your concerns with your doctor is best. Acute psychiatric complications are a terrible potential side effect of prednisone. But since this would likely treat potentially life threatening bleeding, I think the benefit would outweigh this potential risk. Then again, this is a situation in which you and your doctor need to engage in shared decision making. Maybe using the lowest dose possible would also reduce the side effects. I hope this helps.

What are your thoughts?