TXA for Epistaxis with Antiplatelet

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Zahed R. "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.
PubMedFull text

Clinical Question

In adult patients that present to Emerg with anterior epistaxis and concomitant anti-platelet medications, was local application of tranexamic acid superior to antibiotic ointment coated packing for arresting of bleeding?

Bottom Line

Use of topical application of injectable tranexamic acid was superior to standard packing in terms or arrest of bleeding within 10 minutes, faster discharge from Emerg, with a decreased rate of rebleeding within the first 24 hours or 7 days.

Major Points

Non-traumatic intractable epistaxis is a fairly common presenting complaint in Emerg. It is a common challenge for treatment as standard of care requires packing which can be uncomfortable for patients and requires further evaluation by a healthcare professional to remove the packing after several days. Tranexamic acid is comparatively inexpensive and has been used topically to control bleeding in a number of settings.[1] This trial used cotton packing soaked in 500mg of tranexamic acid, compared to vasoconstriction with epinepherine and lidocaine, followed by packing that was removed after 3 days. In this trial 73% in the transexamic group had bleeding arrest within 10 minutes compared to 29% (P<0.001) in the anterior nasal packing. Discharge within 2 hours occurred in 97% of the tranexamic acid group compared to 13% (P<0.001).

There are several limitations with this trial, similar to the previous trial by the same authors TXA for Epistaxis. The first was the untrue blinding of the participants and the clinicians. There was also an inbalance between the two groups with more history of epistaxis in the tranexamic acid group. Finally the primary outcome is unclear: in the tranexamic acid group the packing was removed every 5 minutes to assess for arrest of bleeding whereas in the anterior packing group the evaluation was not described but the packing was removed after 3 days. There are several other commercially available treatments for epistaxis as well as other formulations of tranexamic acid. Given the wide availability of this drug and the ease this trial suggests of use, this is a promising treatment for anterior epistaxis.

Guidelines

As of March 2018, no guidelines have been published that reflect the results of this trial.

Design

  • two-center, parallel-group, randomized clinical trial
  • N=216
    • Tranexamic Acid (n=62)
    • Anterior packing (n=62)
  • Setting: 2 academic hospital Emerg in Iran
  • Enrollment: October 2015 to April 2016
  • Mean follow-up: 7 days
  • Analysis: Intention to treat
  • Primary Outcome: Bleeding arrest by 10 minutes

Population

Inclusion Criteria

  • acute, new or recurrent, ongoing anterior epistaxis
  • taking antiplatelet drugs (aspirin, clopidogrel, or both)
  • bleeding requiring further treatment following compression for 20 mintues

Exclusion Criteria

  • traumatic epistaxis
  • current anticoagulant drug use
  • inherited bleeding disorders (including hemophilia)
  • inherited platelet disorders
  • international normalize ratio > 1.5
  • shock
  • visible bleeding vessel
  • history of renal disease

Baseline Characteristics

Tranexamic Acid group shown

  • Demographics: Mean age 58 years, 60% male
  • Labs: platelet 298, PT 12.5 seconds, INR 1.05, PTT 32 seconds
  • History of epistaxis 53%
  • History of ASA: 81%

Interventions

  • Tranexamic Acid 500mg/5mL soaked cotton packing, removed after bleeding arrest
  • Anterior Packing: soaked in epinephrine (1:100000) + lidocaine (2%) for 10 minutes, then packing covered with tetracycline removed after 3 days

Outcomes

Comparisons are anterior packing vs. Tranexamic Acid.

Primary Outcomes

Bleeding stop time ≤10 min,%
29 vs. 73 (ARR 44, 95% CI 26 to 57, P < 0.001)

Secondary Outcomes

Median bleeding stop time, min[IRQ]
15[10-20] vs. 10[10-15] (P < 0.001)
Discharge time ≤2 h, %
13 vs. 97 (ARR 84, 95% CI 71 to 91, P < 0.001)
Rebleeding in the first 24 h, %
10 vs. 5 (ARR -5, 95% CI -15 to 5, P = 0.299)
Rebleeding from procedure until 1 week, %
21 vs. 5 (ARR -16, 95% CI -28 to -4, P = 0.007)
Patient satisfaction rate (Visual analogue scale), median[IRQ]
4[3-5] vs. 9[8-9] (P < 0.001)

Adverse Events

Complications in the ED (Nausea/vomiting and intolerance), %
5 vs. 10 (ARR 5, 95% CI -5 to 15, P = 0.299)
Serious adverse events
none reported either arm

Criticisms

  • Did not include posterior epistaxis
  • Did not stratify by anti-platelet so can only comment on class in general
  • Full blinding was not conducted due to product and protocol differences, only analysts were blinded
  • Excluded major risk factors for bleeding in this study, limiting external validity
  • Severity of epistaxis not classified
  • Higher rate of history of epistaxis in Tranexamic acid group
  • Complication of "intolerance" not well defined

Funding

  • Not stated

Further Reading

  1. Ker K et al. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev 2013. :CD010562.