Assessing Topical Tranexamic Acid in patients with Epistaxis on Oral Anticoagulation
Date First Published:
February 4, 2021
Last Updated:
April 22, 2021
Report by:
Frank Battaglia, Resident Physician (McMaster University)
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)
((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)
Outcome:
640 references imported for screening as 640 studies
t96 duplicates removed
544 studies screened against title and abstract
t456 studies excluded
88 studies assessed for full-text eligibility
t86 studies excluded
tt35 Wrong patient population
tt34 Wrong study design
tt10 Wrong intervention
tt3 Unable to access full text
tt1 Paper Retracted
tt1 Wrong comparator
tt1 Wrong indication
tt1 Wrong route of administration
tt1 Incomplete data
t0 studies ongoing
t0 studies awaiting classification
1 study included
t96 duplicates removed
544 studies screened against title and abstract
t456 studies excluded
88 studies assessed for full-text eligibility
t86 studies excluded
tt35 Wrong patient population
tt34 Wrong study design
tt10 Wrong intervention
tt3 Unable to access full text
tt1 Paper Retracted
tt1 Wrong comparator
tt1 Wrong indication
tt1 Wrong route of administration
tt1 Incomplete data
t0 studies ongoing
t0 studies awaiting classification
1 study included
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Epistaxis complicated by rivaroxaban managed with topical tranexamic acid 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 |
Author Commentary:
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.
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:
- Utkewicz MD, Brunetti L, Awad NI, M.D. U, L. B.. Epistaxis complicated by rivaroxaban managed with topical tranexamic acid