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NoPAC RCT – TXA for Epistaxis – Helpful or Useless?

July 6, 2021

Written by Aaron Lacy

Spoon Feed
In this double-blinded RCT, topical TXA was no more effective than placebo in reducing the need for nasal packing in patients with persistent epistaxis.

Why does this matter?
Nosebleeds are common, and packing is painful. If there was an easy and cheap way to reduce the need for nasal packing, it could prevent ED revisits and increase patient comfort.

TXA – The silver (nitrate) bullet for epistaxis control?
This double-blinded, multicenter RCT enrolled patients with persistent epistaxis after 10 minutes of nasal pressure and subsequent topical vasoconstrictor application. 254 were randomized to receive treatment with topical TXA introduced on a cotton wool dental roll and 242 were randomized to receive cotton wool dental rolls soaked in sterile water. There was no difference in need for nasal packing between the group randomized to TXA (43.7%) versus placebo (41.3%) (OR 1.107; 95% CI 0.769 to 1.594; P=.59).

TXA has been touted as a potential silver bullet for a myriad of complaints, including trauma, TBI, postpartum hemorrhage, GI bleed, and more. While it shows benefit for some conditions, the results have always been somewhat mixed (and sometimes controversial), and it hasn’t panned out to be the miracle drug some were hoping. This study is contrasting to prior studies on the use of TXA in epistaxis in that it showed no benefit. Based on ease of use and relatively low cost, I regularly include TXA in my nosebleed arsenal. This study doesn’t support my current practice, and although I like to follow the evidence, I am always hesitant to shove packing into an already miserable patient’s nose. I will probably continue to use TXA, but now with the knowledge that I may only be delaying the inevitable.

Another Spoonful
TXA is a everywhere in the literature – an easy way to read it all is to search Journal Feed for “TXA” and see the many times we have covered these articles.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial. Ann Emerg Med. 2021 Jun;77(6):631-640. doi: 10.1016/j.annemergmed.2020.12.013. Epub 2021 Feb 19.

What are your thoughts?