Recommended Citation: Reyes J. The Cheese - You’re Going to Put TXA Where? [Internet]. Cook County Emergency Medicine Residency. 2023;Available from: https://cookcountyem.com/blog/2023/12/3/the-cheese-youre-going-to-put-txa-where
Ask many an emergency physician their least favorite complaint; a common answer will be epistaxis. Time-consuming, distressing for the patient, and unpredictable for the physician, we are in constant search of the magic bullet. Tranexamic Acid (TXA) was, at one point, imagined to be the answer we were searching for. Here, we aim to discuss TXA uses in mucosal bleeding of a variety of anatomic locations.
Is TXA effective in achieving hemostasis in epistaxis?
A typical protocol utilizing TXA in epistaxis involves soaking a 4x4 gauze in 1 g of TXA and inserting it within the nasal cavity, pretreated with a topical vasoconstrictor such as oxymetazoline, using bayonet forceps. Famously, in 2020 the NoPAC trial, the largest RCT at that point in time recruiting 496 patients, published in the Annals of Emergency Medicine called into question the efficacy of TXA in epistaxis after finding no statistically significant benefit compared to placebo in terms of the need for anterior nasal packing (1). Two years later, another study published in the Annals of Emergency Medicine by Hosseinialhashemi et al. found a contradictory result, noting in their cohort of 240 randomized patients that TXA-treated patients needed less anterior nasal packing and were in the ED for less time (2). The biggest difference in these studies' methodologies was that the former study included patients only after failing nasal pressure and treatment with vasoconstrictors, while the latter forewent this initial step and immediately treated with vasoconstrictors plus TXA soaked gauze.
Answer: It’s unclear at this time whether TXA is better than placebo in achieving hemostasis for epistaxis. If you do decide to trial topical TXA, it should be done sooner rather than later, as early treatment may be the reason for contradictory results in two well-conducted, large RCTs.
Is TXA effective in achieving hemostasis in hemoptysis?
2018 produced us the first RCT on nebulized TX (500 mg TID) for hemoptysis. In this 2018 double-blind, RCT including 47 patients (3) comparing nebulized TXA to placebo and a 2023 open-label RCT including 110 patients (4) comparing nebulized to IV TXA, it was found statistically significant decreases in hemorrhage and lengths of stay. Both studies additionally evaluated need for bronchial artery embolization as a secondary outcome and found a statistically significant need for the procedure in patients receiving nebulized TXA. One study did find two patients in the nebulized TXA arm experienced adverse events, namely bronchoconstriction resolving with beta-agonist therapy.
Answer: TXA appears to be effective in achieving significant hemostasis in hemoptysis. Although these are two small, single-center studies, the significant difference in patient-centered outcomes merits the use of TXA in this condition given it’s non-invasive nature. Notably, the sample sizes of these studies are insufficient to fully evaluate safety parameters, but the potential risk of significant harm likely out weighs the risk of a harm this agent being used in a topical manner.
Is TXA effective in achieving hemostasis in hematuria?
A recent study published in the American Journal of Emergency Medicine from 2023 evaluated intravesical TXA (i.e. 1 g of TXA injected into a foley into the bladder and left in for 15 min) for the management of gross hematuria (5). The current standard of care involves continuous bladder irrigation, which has no prothrombotic properties and therefore would not address someone with active bleeding. This before-and-after, retrospective study compared 159 patients treated for hematuria at a single-center before and after implementing a protocol involving intravesical TXA. They found that patients were in the ED for less time (274 min vs 411 min), were less likely to revisit (2.3% vs 12.3%), and were less likely to be admitted (29.1% vs 45.2%). Although no adverse events were reported, there is concern TXA treatment for hematuria could result in ureteral clot formation resulting in obstructive uropathy (6).
Answer: TXA may be effective in improving hemostasis in hematuria. Although these data are promising and resulted in improvement in multiple patient centered outcomes, treatment for this condition compared to hemoptysis is different due to the fact a significant complication has been described in the literature. Given other benign and safe interventions are available, intravesical TXA could be considered with strong return precautions and conseling, but is not in a place for widespread implementation.
Authored by Jose Reyes, MD
References:
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. doi:10.1016/j.annemergmed.2020.12.013
Hosseinialhashemi M, Jahangiri R, Faramarzi A, et al. Intranasal Topical Application of Tranexamic Acid in Atraumatic Anterior Epistaxis: A Double-Blind Randomized Clinical Trial. Ann Emerg Med. 2022;80(3):182-188. doi:10.1016/j.annemergmed.2022.04.010
Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379-1384. doi:10.1016/j.chest.2018.09.026
Gopinath B, Mishra PR, Aggarwal P, et al. Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial. Chest. 2023;163(5):1176-1184. doi:10.1016/j.chest.2022.11.021
Choi H, Kim DW, Jung E, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023;68:68-72. doi:10.1016/j.ajem.2023.03.020
Lee SG, Fralick J, Wallis CJD, Boctor M, Sholzberg M, Fralick M. Systematic review of hematuria and acute renal failure with tranexamic acid. Eur J Haematol. 2022;108(6):510-517. doi:10.1111/ejh.13762