Thursday, 7 May 2015

Epistaxis treatment using injectable form of tranexamic acid topically: why not


 I've done my share of bootlegging. Up 'ere, if you engage in what the federal government calls 'illegal activity,' but what we call 'just a man tryin' to make a livin' for his family sellin' moonshine liquor,' it behooves oneself to keep his wits. Long story short, we hear a story too good to be true... it ain't.       Lt Aldo Raine “Inglourious Basterds” 2009


This study out of Tehran, Iran looked at using the injectable form of tranexamic acid (TXA) to control uncomplicated anterior epistaxis.

This was a single centre unblinded randomized controlled trial. In the experimental group a 15cm piece of cotton pledget was soaked in tranexamic acid (500mg/5ml) and was inserted in the nostril. It was removed shortly after it was determined that the bleeding had stopped. The control group had standard anterior nasal packing that was removed after 3 days.

216 patients were randomized and there was no loss to follow up. The methods did not really specify a primary outcome but they did report numerous “efficacy variables.”

Within 10 minutes of treatment, the bleeding had stopped in 71% of the TXA group compared with 31% of the control. In addition, 95% of those treated with TXA were discharged from the ED in 2 hours or less compared to 6% in the controls.

This treatment effect is way too good to be true. There must have been some systematic bias that accounted for the profound differences in early discharge of the TXA group. This is never really explained in the discussion section of the paper. 

The numerous grammatical errors in the text do make the paper appear a bit sloppy and hard to read. It should be the job of the journal editor to ensure that these errors do not make it to print. But heck, this isn't exactly a high impact journal.

Unfortunately, this study excluded complicated epistaxis. These are precisely the patients who may require some extra finesse and it would be nice to know if there was some efficacy of TXA in this population.

Despite all of this, I think the notion of topical TXA treatment for epistaxis is compelling. Many other large studies over decades have shown it to be reasonably safe. Not only is TXA unlikely to cause harm but it is dirt cheap. We have vials of TXA in my ED that cost $6 a vial.

The bottom line? I think it is reasonable to try the injectable form of TXA topically as an adjunct to help control epistaxis. Why not?  But please don’t expect the miracle cure that this paper purports.


Covering:

Zahed R, Moharamzadeh P, AlizadehArasi S, et al. A new and rapid method for epistaxis treatment using injectable form of trenexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31:1389-1392.


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