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TXA for Epistaxis Just Can’t Make up its Mind

Written by John Korducki

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This single center, double blinded, randomized control trial of 240 patients demonstrated several positive outcomes with addition of tranexamic acid (TXA) to standard therapy.

Why does this matter?
Epistaxis is a common presenting complaint to the ED, and the efficacy of TXA in epistaxis management has been hotly debated in the literature lately.

Everyone hates packing…
Any list of “worst things ever” would be remiss to not mention multiple forms of packing (moving boxes, luggage, and, yes…nasal). The goal of topical TXA is often to avoid nasal packing, which is poorly tolerated by patients and may require a course of prophylactic antibiotics, depending on the clinician. Frankly, the literature on TXA in epistaxis is confusing. Earlier studies did not demonstrate benefits of TXA1-3, but it gained some steam after some small, unblinded studies4-6 and a systematic review7 by Joseph et al demonstrated positive outcomes such as reduced bleeding time and decreased re-bleeding. Then came the NoPAC trial,8 which was a double-blinded RCT across 26 EDs that evaluated TXA as a second line agent following compression and vasoconstrictors and showed no difference between rates of packing, need for transfusion, or hospital admission. NoPAC greatly slowed the TXA hype train.

However, no good story ends without redemption. A 2022 systematic review and meta-analysis of 1,299 patients demonstrated improved bleeding cessation at first reassessment and lower recurrence with TXA, but this study notably did not include NoPAC.9 This current study, a double-blinded RCT to evaluate TXA as a first line agent in addition to topical vasoconstrictors versus vasoconstrictors alone, demonstrated decreased need for anterior nasal packing (OR 0.56), decreased 24-hour rebleeding (OR 0.41), and shorter ED stays (OR 0.38). This is the highest quality study to date demonstrating positive effects of TXA. The limitations are that this trial was performed at a specialty ENT ED; TXA was not utilized as a monotherapy, and relatively few patients were on anticoagulation compared with other studies.

So where does this leave us with TXA? I think it lies with individual provider preference. For me, TXA is low cost, has minimal downsides, and is probably worth adding to the kitchen sink before pivoting to the dreaded packing.

Source
Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022 Jun 22;S0196-0644(22)00247-5. doi: 10.1016/j.annemergmed.2022.04.010. Online ahead of print.

Works Cited

  1. Kamhieh Y, Fox H. Tranexamic acid in epistaxis: a systematic review. Clin Otolaryngol. 2016;41(6):771-776.
  2. Musgrave KM, Powell J. A systematic review of anti-thrombotic therapy in epistaxis. Rhinology. 2016;54(4):292-391.
  3. Tibbelin A, Aust R, Bende M, et al. Effect of local tranexamic acid gel in the treatment of
  4. Akkan S, Çorbacıo!glu S ̧K, Aytar H, et al. Evaluating effectiveness of nasal compression with tranexamic acid compared with simple nasal compression and Merocel packing: a randomized controlled trial. Ann Emerg Med. 2019;74(1):72-78.
  5. Whitworth K, Johnson J, Wisniewski S, et al. Comparative effectiveness of topically administered tranexamic acid versus topical oxymetazoline spray for achieving hemostasis in epistaxis. J Emerg Med. 2020;58(2):211-216.
  6. Zahed R,MousaviJazayeri MH,Naderi A,et al.Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial. Acad Emerg Med. 2018;25(3):261-266.
  7. Joseph J, Martinez-Devesa P, Bellorini J, et al. Tranexamic acid for patients with nasal haemorrhage (epistaxis). Cochrane Database Syst Rev. 2018;12(12):CD004328.
  8. Reuben A, Appelboam A, Stevens KN, et al. The use of tranexamic acid to reduce the need for nasal packing in epistaxis (NoPAC): randomized controlled trial. Ann Emerg Med. 2021;77(6):631-640.
  9. Janapala RN, Tran QK, Patel J, Mehta E, Pourmand A. Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis. Am J Emerg Med. 2022;51:169-175. doi:10.1016/j.ajem.2021.10.043

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