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Noses Say Yay for TXA!

February 17, 2022

EEM 2022 Competition Winner!

Don’t miss tomorrow’s in depth post on the clinical controversy of TXA for epistaxis. It is written by the winner of the EEM 2022 JournalFeed blog post competition, Matthew Stampfl!

In the meantime, let’s “unpack” this topic.

Written by Lisa Birdsall Fort

Spoon Feed
TXA is a safe and effective topical treatment for epistaxis, with 3.5 times greater odds of bleeding cessation at first reassessment compared to placebo, lidocaine plus vasoconstrictors, or local anesthetics.

Why does this matter?
Epistaxis is very common.  This presentation accounts for 1 in 200 ED visits in the United States.  Topical vasoconstrictors and anesthetics which constitute usual care often do not stop bleeding. Invasive treatments like nasal packing, cautery and surgical ligation can be risky and painful.  Rebleeding is also common, with frequently reported repeat visits between 24-72 hours and up to 7-8 days after initial visit.

Noses say YAY for TXA!!!
This was a systematic review and meta-analysis with 2,394 studies identified from databases with exclusion of nonclinical, non-observational studies and trials with further exclusion of reports including IV TXA, epistaxis related to surgery, and expert opinion/perspective articles.  8 studies were included in the analysis: 7 RCTs and 1 retrospective study, with total of 1,299 patients.  Primary outcome was bleeding cessation at first reassessment.  The topical TXA group was associated with 3.5-times greater odds of bleeding cessation (OR 3.5 with 95% CI 1.9-9.7 p=0.014) compared to alternative control measures.  Subgroup analysis further suggested higher odds of bleeding cessation with TXA compared to vasoconstrictor (epinephrine, phenylephrine, or oxymetazoline) with OR 7.8 95% CI 4.5-13 P = 0.001.  Other outcomes in 5 studies that reported rate of return between 24-72 h showed 63% lower likelihood of return in the TXA group.  Begg’s and Egger’s tests suggested lower likelihood of publication bias.  No statistically significant difference in adverse events was found in the analysis.  This evidence is convincing enough that I will start using topical TXA as my first choice for treatment.  Of course, I’ll still teach patients how to put the right pressure in the right place for the right amount of time.

Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis. Am J Emerg Med. 2022 Jan;51:169-175. doi: 10.1016/j.ajem.2021.10.043. Epub 2021 Nov 1.

What are your thoughts?