Does topical tranexamic acid (TXA) work for stopping nasal bleeding (epistaxis)?

From the Guidelines

Topical tranexamic acid (TXA) is effective for stopping epistaxis (nosebleeds) and should be considered as a first-line treatment option. When applied directly to the bleeding site, TXA helps control bleeding by inhibiting the breakdown of blood clots, allowing them to form and remain stable. For epistaxis management, a typical approach involves soaking a cotton pledget or gauze with TXA solution (typically 500 mg/5 mL concentration) and applying it directly to the bleeding site with gentle pressure for 10-15 minutes. Alternatively, TXA-soaked packing can be inserted into the nasal cavity. The medication works locally by inhibiting plasminogen activation, which prevents the dissolution of fibrin clots that form at the bleeding site. This mechanism makes TXA particularly useful for anterior nosebleeds, which are the most common type.

Key Points to Consider

• Topical TXA has been shown to be effective in controlling epistaxis in patients with anterior nosebleeds, including those taking antiplatelet drugs 1.
• The use of topical TXA has been associated with higher rates of acute bleeding control and earlier discharge compared to anterior nasal packing 1.
• Topical TXA has the advantage of causing fewer systemic side effects compared to oral or intravenous administration while still providing effective hemostasis.
• For patients with recurrent or difficult-to-control epistaxis, keeping TXA solution at home for early application may help prevent severe bleeding episodes and reduce emergency department visits.

Clinical Application

In clinical practice, topical TXA can be used as a first-line treatment option for epistaxis, particularly for anterior nosebleeds. The solution can be applied directly to the bleeding site using a cotton pledget or gauze, and gentle pressure can be applied for 10-15 minutes to help control bleeding. It is essential to note that while topical TXA is effective, it may not be suitable for all patients, and individual patient factors should be considered when determining the best course of treatment.

Evidence-Based Recommendation

The recommendation to use topical TXA for epistaxis is based on the most recent and highest-quality evidence available, including a study published in 2020 that demonstrated the effectiveness of topical TXA in controlling epistaxis in patients with anterior nosebleeds 1. Additionally, a Cochrane review published in 2020 noted the benefits of using TXA for nosebleed control, including a reduction in rebleed rates 1. However, it is essential to consider the limitations of the available evidence and the need for further studies to fully understand the indications and efficacy of TXA for epistaxis control.

From the Research

Topical TXA for Epistaxis

• Topical tranexamic acid (TXA) has been studied as a treatment for epistaxis, with varying results 2, 3, 4, 5, 6.
• A literature review found that topical agents such as oxymetazoline can stop 65-75% of nosebleeds, while tranexamic acid promotes hemostasis in 78% of patients 2.
• A randomized controlled trial compared topical TXA with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs, and found that TXA stopped bleeding in 73% of patients within 10 minutes, compared to 29% with nasal packing 3.
• A systematic review and meta-analysis found that topical TXA was associated with better bleeding cessation rates after treatment compared to standard practices, with patients 3.5 times more likely to achieve bleeding cessation at the first assessment 4.
• However, a randomized controlled trial found that topical TXA was no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing in patients with atraumatic epistaxis 6.

Efficacy of Topical TXA

• The efficacy of topical TXA for epistaxis has been demonstrated in some studies, with bleeding cessation rates ranging from 73% to 78% 2, 3, 4.
• However, other studies have found that topical TXA is not more effective than placebo or standard treatments, such as nasal packing 5, 6.
• The use of topical TXA may be beneficial in certain patient populations, such as those taking antiplatelet drugs, but further research is needed to determine its effectiveness in different clinical scenarios 3.

Comparison with Other Treatments

• Topical TXA has been compared to other treatments for epistaxis, including nasal packing, cauterization, and surgical ligation 2, 3, 4, 5, 6.
• While some studies have found that topical TXA is more effective than these treatments, others have found that it is not more effective than placebo or standard treatments 3, 6.
• Further research is needed to determine the optimal treatment for epistaxis and to compare the efficacy of different treatments, including topical TXA 2, 4.