#388 Stop the Drip: Tranexamic Acid Solution for Nosebleeds
CLINICAL QUESTION
Can topical tranexamic acid treat epistaxis?
BOTTOM LINE
Tranexamic acid intravenous solution applied to a cotton pledget increases the proportion of patients who stop bleeding within 10 minutes from 55% (saline) to 82%. Based on 1 randomized controlled trial (RCT), tranexamic acid may be better than vasoconstrictors (ie. phenylephrine-lidocaine) with 90% stopping bleeding at 10 minutes versus 14% (vasoconstrictors). However, efficacy of combining agents is unclear.
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EVIDENCE
- Results statistically significant unless indicated.
- Reporting RCTs due to different comparators. RCTs mostly used 500-1000mg of 100mg/ml tranexamic acid (TXA).
- TXA alone; 2 RCTs versus saline.
- RCT, 152 participants, 500-1000mg tranexamic-acid:1
- Proportion of patients who stopped bleeding within 10 minutes: 82% (1000mg) versus 72% (500mg) versus 55% (saline). Statistically significant for 1000mg versus saline only (PEER calculation), Number Needed to treat (NNT)=4.
- Proportion re-bleeding within 24 hours: 6% (1000mg) versus 10% (500mg) versus 29% (saline). (NNT)=5-6.
- Other RCT, 90 participants: similar.2
- RCT, 152 participants, 500-1000mg tranexamic-acid:1
- TXA versus vasoconstrictor; 1 RCT, 100 participants on ASA/clopidogrel.3
- Mean bleeding time: 6.7 minutes versus 11.5 minutes (phenylephrine-lidocaine).
- Stopped bleeding within 10 minutes: 90% versus 14% (phenylephrine-lidocaine), NNT=2.
- Re-bleeding within 72 hours: 6% versus 20% (phenylephrine-lidocaine), NNT=8.
- TXA with phenylephrine-lidocaine versus phenylephrine-lidocaine; 1 RCT, 240 participants:4
- Nasal packing: 50% versus 64% (phenylephrine-lidocaine alone), NNT=8.
- Re-bleeding within 24 hours: 15% versus 30% (phenylephrine-lidocaine alone), NNT=7.
- TXA (200-400mg) after topical vasoconstrictor versus water; 1 RCT, 496 participants:5
- Nasal packing (~42%), hospitalization (~45%): no difference
- Limitations: Older patients (age~71) with co-morbidities, 65% on anti-coagulants, lower doses used.
- TXA versus nasal packing; RCTs showed equivalent2 or superior to nasal packing.6--8
- Adverse events similar to placebo.5
- Limitations: No RCTs of TXA plus vasoconstrictor versus TXA alone, no RCTs in children.
CONTEXT
- Epistaxis chief complaint in 1/313 emergency room visits. ~20% resolve with external pressure.9
- Role of tranexamic acid not clearly outlined in guidelines.10
- Evidence supporting the efficacy of topical vasoconstrictors in epistaxis is limited even though commonly used.
- Cost 10mL ~$10,11 IV solution applied cotton pledget prior to insertion into nostril.
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Can tranexamic acid topical be used in patients with hx of TIA/Stroke?
excellent idea
GOOD WAY TO TREAT
Tried this in ER with great success…
Makes sense that would work
Excellent idea
Local application of tranexemic acid is more effective than only saline soaked packing.
I did not know that
Topical TXA works for nosebleeds.
Concise article