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#388 Stop the Drip: Tranexamic Acid Solution for Nosebleeds


CLINICAL QUESTION
QUESTION CLINIQUE
 Can topical tranexamic acid treat epistaxis?

BOTTOM LINE
RÉSULTAT FINAL
 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
DONNÉES PROBANTES
  • 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
  • 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
CONTEXTE
  • 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.

Rohit Chadha May 18, 2025

excellent idea

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Author(s)
Auteur(s)
  • Émélie Braschi MD PhD
  • Jennifer Young MD CCFP-EM

1. Arikan C, Akyol PY. Sci Prog. 2024 Oct-Dec;107(4):368504241264993.

2. Akkan S, Çorbacıoğlu ŞK, Aytar H, et al. Ann Emerg Med. 2019 Jul;74(1):72-78.

3. Amini K, Arabzadeh A, Jahed S, et al. Arch Acad Emerg Med. 2020 Nov 19;9(1):e6.

4. Hosseinialhashemi M, Jahangiri R, Faramarzi A, et al. Ann Emerg Med. 2022 Sep;80(3):182-188.

5. Reuben A, Appelboam A, Stevens KN, et al. Ann Emerg Med. 2021 Jun;77(6):631-640.

6. Chaitanya V, Manampuram MT, Sreelakshmi PS et al. Indian J Otolaryngol Head Neck Surg. 2024 Aug;76(4):3066-3070.

7. Zahed R, Moharamzadeh P, AlizadehArasi S, et al. Am J Emerg Medicine. 2013 Sep;31(9):1389-1392.

8. Zahed R, Jazayeri MHM, Naderi A, et al. Acad Emerg Med. 2018 Mar;25(3):261-266.

9. Biadsee A, Gob A, Sowerby L. CMAJ. October 03, 2022 194 (38) E1322.

10. Tunkel DE, Anne S, Payne SC, et al. Otolaryngol Head Neck Surg. 2020 Jan;162(1_suppl):S1-S38.

11. Tranexamic Acid Prices, Coupons, Copay Cards & Patient Assistance. https://www.drugs.com/price-guide/tranexamic-acid. Accessed on Nov 1st 2024.

Authors do not have any conflicts of interest to declare.