Intranasal Tranexamic Acid Dosing for Epistaxis
The recommended dose is 500 mg of tranexamic acid (5 mL of the injectable formulation) applied topically to the bleeding nostril using cotton pledgets or dental rolls, with bleeding typically controlled within 10 minutes. 1
Topical Application Method
Apply 500 mg tranexamic acid in 5 mL (the standard injectable formulation) directly to the bleeding nostril using cotton pledgets or dental rolls soaked in the solution. 1
The injectable form is repurposed for topical use—this is the most practical and widely studied approach in emergency settings. 1, 2
Leave the soaked pledget in place for at least 10 minutes to allow adequate contact time with the bleeding site. 1
Expected Efficacy and Timing
Bleeding stops within 10 minutes in approximately 70% of patients treated with topical TXA, compared to only 30% with anterior nasal packing. 1
In one trial, 71% of patients achieved hemostasis within 10 minutes with topical TXA versus 31.2% with traditional anterior nasal packing (OR 2.28,95% CI 1.68-3.09). 1
A more recent study showed 76% (38/50 patients) achieved hemostasis within 10 minutes with topical TXA compared to 34% (17/50) with gelfoam packing. 2
Important Caveats About the Evidence
However, the largest and highest-quality trial (NoPAC, 2021) found NO benefit of topical TXA over placebo in reducing the need for nasal packing. 3
This multicenter, double-blind RCT of 496 patients showed no difference in packing rates: 43.7% in the TXA group versus 41.3% in the placebo group (OR 1.107,95% CI 0.769-1.594). 3
The NoPAC trial contradicts earlier smaller studies and suggests topical TXA may not be effective when rigorously tested against placebo. 3
The discrepancy likely reflects that earlier studies compared TXA to nasal packing (not placebo), and packing itself may be less effective than previously assumed. 3
Oral TXA as Alternative
For recurrent epistaxis or cases not responding to topical measures, oral tranexamic acid 500 mg twice daily (titrated up to 1000 mg four times daily or 1500 mg three times daily) is recommended. 4
Oral TXA reduces rebleeding risk from 69% to 49% over 10 days (RR 0.73,95% CI 0.55-0.96). 5
This is particularly useful for hereditary hemorrhagic telangiectasia patients with recurrent epistaxis. 6
Contraindications include recent thrombosis; relative contraindications include atrial fibrillation and thrombophilia. 4
Critical Clinical Pitfalls
Do not rely solely on topical TXA as a substitute for proper visualization and cauterization of the bleeding source. 7
If topical TXA fails, proceed immediately to nasal endoscopy to identify the bleeding site, followed by bipolar electrocautery if needed. 7
In anticoagulated patients, do not reverse anticoagulation if bleeding can be controlled with local measures—TXA and other antifibrinolytics support hemostasis without reversing anticoagulation. 4
Given the conflicting evidence, topical TXA should be considered an adjunct to—not a replacement for—standard epistaxis management including direct pressure, vasoconstrictor application, and cauterization when indicated. 3