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Three Part Question

In [a patient with epistaxis on oral anticogulation] is [topical tranexamic acid effective] in [improving mortality, measure bleeding events, or ED return visits]?

Clinical Scenario

Mrs. Majorie Knowsbleed is a 75 year old woman, with history of avalvular atrial fibrillation, on Apixaban, presenting to the ED for 2 hours of atraumatic epistaxis. In your arsenal of epistaxis management, you consider the utility of topical tranexamic acid to stop the bleeding.

Search Strategy

OVID Medline and EMBASE
((Epistaxis.mp or exp Epistaxis/) OR Nose bleed$.mp) AND (DOAC.mp OR NOAC.mp OR (Coagulant$.mp or exp Coagulants/) OR Coagulation.mp OR (Anticoagulant$.mp or exp Anticoagulants/) OR Anticoagulation.mp OR Apixaban.mp OR Eliquis.mp OR (Dabigatran.mp or exp Dabigatran/) OR Pradaxa.mp OR Edoxaban.mp OR Lixiana.mp OR Sawaysa.mp OR (Rivaroxaban.mp or exp Rivaroxaban/) OR Xarelto.mp OR (Warfarin.mp or exp Warfarin/) OR Coumadin.mp OR (Factor Xa inhibit$.mp or exp Factor Xa Inhibitors/) OR Thrombin inhibit$.mp OR Betrixaban.mp OR Bevyxxa.mp OR Darexaban.mp OR YM150.mp OR Otamixaban.mp OR INN.mp OR Letaxaban.mp OR TAK-422.mp OR Eribaxaban.mp OR PD0348292.mp) AND ((exp Antifibrinolytic Agents/ or exp Tranexamic Acid/ or TXA.mp) OR Tranexamic Acid.mp OR Antifibrinoly$.mp OR Cyklokapron.mp)

Search Outcome

640 references imported for screening as 640 studies
96 duplicates removed
544 studies screened against title and abstract
456 studies excluded
88 studies assessed for full-text eligibility
86 studies excluded
35 Wrong patient population
34 Wrong study design
10 Wrong intervention
3 Unable to access full text
1 Paper Retracted
1 Wrong comparator
1 Wrong indication
1 Wrong route of administration
1 Incomplete data
0 studies ongoing
0 studies awaiting classification
1 study included

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Utkewicz MD, Brunetti L, Awad NI, M.D. U, L. B. 2015 USA	Single patient 82-year-old man on rivaroxaban, unilateral epistaxis, 500mg topical intranasal tranexamic acid	Case Report	Time to hemostasis	Cessation of epistaxis within 20 minutes of intranasal tranexamic acid application	Single patient case report Single arm

Comment(s)

No present methodologically rigorous studies on clinical populations performed to assess management of epistaxis with tranexamic acid in patients on oral anticoagulation. There is evidence equivalency of outcomes when treating patients presenting with epistaxis with topical tranexamic acid, but with a growing population of patients on oral anticoagulation, further studies are needed.

Clinical Bottom Line

There is minimal evidence to support or dissuade intranasal tranexamic acid application for patients on oral anticoagulation presenting to the Emergency Department with epistaxis.

References

1. Utkewicz MD, Brunetti L, Awad NI, M.D. U, L. B. Epistaxis complicated by rivaroxaban managed with topical tranexamic acid American Journal of Emergency Medicine 2015;33(9):1329e5-1329e7