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Three Part Question

In [adults with spontaneous, uncomplicated epistaxis,] is [topical tranexamic acid] effective at [stopping bleeding and preventing subsequent rebleeding]?

Clinical Scenario

A 55 year old man presents to the emergency department with spontaneous epistaxis. He is haemodynamically stable. Simple first aid measures including pinching the soft portion of the nose were ineffective at arresting the bleeding. The patient is previously well with no comorbidities.

You are aware that tranexamic acid is effective as an antifibrinolytic in various bleeding conditions and anticipate it may be useful topically at stopping bleeding in epistaxis.

Search Strategy

Medline 1996 – 2013 using the OVID interface
((exp Tranexamic AND acid) OR (antifibrin$)) AND ((exp epistaxis) OR (exp nose AND exp bleed))

Search Outcome

33 papers of which 2 were relevant. The majority of publications are case reports and series, with few controlled trials

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tibbelin A et al 1995 Sweden	Adult patients presenting with uncomplicated, ongoing nosebleed	Randomised controlled trial (level A) with 68 patients enrolled across 3 clinics	Arresting bleeding in 30minutes:	60% in TXA group vs. 76% placebo. (p=0.16 n.s.)	Small study. Aims and objectives not stated No evidence of power or sample size calculation No explanation of randomisation method Baseline characteristics between the two groups were not similar TXA group was assigned significantly more moderate and severe bleeds Trend towards benefit with placebo in terms of stopping bleeding within 30 minutes (60% vs 76%)
			Rebleeding within 8 days:	11% in TXA group vs. 31% placebo (p=n.s.)
			Rebleeding within 30 days:	44% in TXA group vs. 66% placebo (p=n.s.)
Zahed R et al 2013 United States	216 patients presenting to an Emergency Department with on-going anterior epistaxis	Randomised controlled trial (level A)	The frequency of patients with epistaxis stopped within 10 minutes of treatment;	71% in TXA group vs. 31.2% in anterior nasal packing group (OR, 2.28; 95% CI, 1.68-3.09;P< .001)	Patient selection criteria unclear. Patients randomly selected from all patients with on-going epistaxis, but this process was not described in any detail. No mention of any pre-hospital or in-department first aid measures to arrest bleeding prior to packing. Unclear whether, if attempted, such measures may have been useful. Exact nature of interventions not clear. All patients had some form of nasal pack inserted. Topical lignocaine not applied to both treatment and control groups and similarly topical vasoconstrictor (adrenaline) was not considered standard treatment in both. Patients and attending clinicians not blinded Failed to reach target recruitment (109, 107 vs 110)
			Hours needed to stay in hospital;	95.3% in TXA group discharged in ≤2h vs. 6.4% in anterior nasal packing group (P<.001)
			Frequency of patients with rebleeding within 24 hours and 7 days;	Rebleeding in 4.7% Vs 11% (P=.128)
			Patient satisfaction (rated by a 0-10 scale)	Satisfaction rate higher in the TXA group (8.5 ± 1.7 vs 4.4 ± 1.8,P<.001)

Comment(s)

No robust randomised controlled trials exist that precisely address the proposed question. Specifically, no papers examine the effect of topical intranasal tranexamic acid in all-comers presenting to the emergency department with spontaneous epistaxis. Topical tranexamic acid is widely used by haematologists in patients with bleeding disorders such as hereditary haemorrhagic telangiectasia, hence most of the published reports are case series based on patients with such conditions. Anecdotal evidence supports its use in uncomplicated epistaxis and as an option that is readily available, cheap and with no adverse effects might be worth considering to avoid the need for anterior nasal packing, which is recognised to be uncomfortable and not without its potential for complications.

Clinical Bottom Line

There is insufficient evidence to support the use of topical intranasal tranexamic acid in the management of spontaneous epistaxis in haemodynamically stable patients presenting to the emergency department. Further work is required if this question is to be appropriately answered.

References

1. Tibbelin A, Aust R, Bende M et al. Effects of local tranexamic acid gel in the treatment of epistaxis. J Otorhinolaryngol Relat Spec 1995;57:207–9.
2. Zahed R, Moharamzadeh P, Alizadeharasi S et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial Am J Emerg Med 2013;31:1389–92.