Topical TXA for Epistaxis in Patients on Antiplatelet Agents

Epistaxis is a common emergency department (ED) presentation, particularly in patients on antiplatelet and anticoagulation agents. Traditional remedies for bleeding include local vasoconstrictors, silver nitrate, and anterior nasal packing (ANP), each with variable efficacy. In recent years tranexamic acid (TXA) applied topically has gained popularity due to its efficacy, minimal systemic absorption lending to a low side-effect profile, and ease of use for the patient and provider (Zahed, Am J Emerg Med 2013; Ker, Cochrane Database Syst Rev 2013). In this recently published study, Zahed et al narrowed their focus to explore clinical efficacy of topical TXA in patients on antiplatelet agents (aspirin, clopidogrel, or both).

What They Did

  • 2-armed, randomized, unblinded, parallel-group trial conducted in 2 EDs in Tehran
  • Inclusion criteria: Acute, new, or recurrent anterior epistaxis unremitting after 20 minutes of manual compression in patients on aspirin, clopidogrel, or both
  • Exclusion criteria: Trauma, current anticoagulation and/or INR > 1.5, inherited bleed and/or platelet disorders, shock, visible bleeding vessel, renal disease
  • Randomized to TXA (500mg in 5mL) soaked cotton pledget placed until bleed cessation OR pretreatment with cotton pledge soaked in epinephrine (1:100,000) and lidocaine (2%) for 10 minutes followed by ANP left in place for 3 days
  • Primary endpoint: Proportion of patients with bleeding cessation at 10 minutes post nasal packing or topical TXA application
  • Secondary endpoints: Proportion of patients with re-bleed at 24-hours and one week post treatment, ED length of stay, and patient satisfaction

What They Found

Population

  • 124 patients randomized (62 in each group)
    • 57 patients per group needed to reach 80% power with an alpha of 0.05
  • No patients lost to follow-up
  • ~80% of patients in each group on aspirin as their antiplatelet agent
  • More patients in the TXA group with history of epistaxis (53% vs 21%)

Results

ANP TXA Difference p-value
Bleed stop time at 10 min (%) 29 73 44 (26 to 57) <0.001
Bleed stop time (min), median [IQR] 15 [10-20] 10 [10-15] <0.001
Discharge time less than 2 hours (%) 13 97 84 (71 to 91) <0.001
Complications in ED (%) 5 10 5 (-5 to 15) 0.299
Rebleeding in the first 24 hours (%) 10 5 -5 (-15 to 5) 0.229
Rebleeding within 1 week (%) 21 5 -16 (-28 to -4) 0.007
Patient Satisfaction 0-10 (median) 4 9

Thoughts

  • The authors did not report the percentage of patients who had bleed cessation after the application of lidocaine with epinephrine prior to nasal packing which may be a more relevant comparison to topical TXA
  • Although a significantly greater proportion of patients in the TXA arm achieved bleeding cessation after 10 minutes, the median difference in time to bleed cessation was 5 minutes, which although statistically significant is likely not clinically significant in most patient scenarios
  • Details surrounding the increased percentage of patients with complications in the TXA group were not described in this study which leaves many question marks
  • Median time to bleed within the 7-day follow-up period for the ANP arm was not provided which would have given a clue as to whether the rebleed was due to mucosal irritation with packing removal and not necessarily therapeutic failure
  • We stock the 1000 mg/10 mL solution of TXA in our ED, which makes for fast preparation for epistaxis, oral bleeding, or trauma

Application to Clinical Practice

Clinicians should trial topical TXA in patients with anterior epistaxis who fail manual compression due to its quick effect, attractive safety profile, and non-invasive application prior to more aggressive strategies.

Further Reading

Dr. Anand Swaminathan shared his critique of the study on the R.E.B.E.L. EM blog

R.E.B.E.L. EM also has a summary of the older data in a practical post Topical Tranexamic Acid for Epistaxis or Oral Bleeds

Reference

Zahed R 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):261-6. PMID 29125679

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