The use of tranexamic acid to reduce the need for nasal packing in epistaxis (NoPAC): randomized controlled trial
Reuben A, Appelboam A, Stevens KN, et al. Ann Emerg Med. Published online February 18, 2021. doi:10.1016/j.annemergmed.2020.12.013
Topical tranexamic acid (TXA) has been suggested as a treatment option for epistaxis. Although several recent meta-analyses have suggested TXA’s effectiveness, the studies are based on very small trials with highly variable methods.
This is a large double-blind randomized trial from 26 EDs in the U.K. evaluating the effectiveness and safety of topical TXA in adults with spontaneous atraumatic epistaxis who had persistent bleeding after pressure and/or ice application.
All patients were treated with a topical vasoconstrictor on a cotton roll for 10 minutes.
The intervention was 4 mL (400 mg) of TXA or placebo, given in 1 or 2 doses: a cotton-wool dental roll soaked in half the trial solution was inserted into the bleeding nostril for 10 minutes, and if epistaxis persisted, a second trial treatment (with the remaining 2 mL of trial solution) was applied in the same manner. Further treatment decisions were at the discretion of the treating clinician.
The study randomized 496 participants >70 years of age whose use of anticoagulants was high (68.6% placebo vs 61.0%).
The rate of anterior packing (primary outcome) was 43.7% in the TXA group vs 41.3% in the placebo group. Among only the patients taking anticoagulants, no differences were found between groups.
No differences were found in any secondary outcomes assessed, including hospital admission, the need for blood transfusion, recurrent epistaxis, and thrombotic events within 1 week.
Study limitations include that although the goal enrollment was achieved, the trial might have been underpowered, because the sample size was based on a predicted packing rate of 95%, but approximately 40% of cases were packed. Moreover, previous studies have used a higher dose of TXA (500 mg) for treatment. Finally, the admission rate exceeded 40%; although this rate seems high relative to those in the U.S., the authors state that packed patients are normally admitted in the U.K.
EDITOR’S COMMENTARY: In this large randomized trial from the UK among adults with spontaneous atraumatic epistaxis, the authors did not find value in topical TXA over placebo. It is possible that the trial was underpowered to detect a difference, but regardless, an important take-home message is that pressure and topical vasoconstrictors work very well for most cases seen in the ED, even among older, anticoagulated patients. TXA is very polarizing, and here we have another large negative trial.