HWN Suggests

Does TXA work for everything? For anything?

The last few years have seen a number of controversial trials involving tranexamic acid (TXA). WOMAN and CRASH-3 were both negative trials, but with potentially interesting secondary analyses that resulted in them being widely advertised as positive. What you make of those secondary analyses will depend a lot on how much you believe in TXA in general.

After CRASH-2, TXA was hailed as a wonder drug, but does it deserve that reputation?

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Featured

  Is TXA Associated with VTE?

Most trauma programs can be divided into two types: those that believe in tranexamic acid (TXA) and those that don’t. I won’t get into the details of the CRASH-2 study here. But those centers that don’t believe usually give one of two reasons: they don’t think it works or they think the risk of venous thromboembolism (VTE) is too high.

  TXA in the Urgent Care

TXA is a cheap and effective treatment for bleeding and has multiple applications in the urgent care setting. The use of TXA in the UC setting is off-label and is not supported by any large randomized control trials.

 The Evidence for TXA – Should Tranexamic Acid Be Routine Therapy in the Bleeding Patient?

TXA has been widely adopted as an effective drug for improving outcomes of patients who are bleeding from a variety of sources, even though many of the trials’ conclusions are contentious.

 The Times they are a Changin' for TXA in Epistaxis?

We would have tweaked their conclusions to say “In select patients (majority taking anticoagulant medication) presenting to an ED with atraumatic epistaxis that is uncontrolled with simple first aid measures and the application of a topical vasoconstrictor, 200mg-400mg of TXA applied in the bleeding nostril on a cotton wool dental roll is no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing”.

 Tick. Tock. It’s Time For a TXA Update

We will review TXA in the context of gastrointestinal bleeding, traumatic brain injuries, hemoptysis, intracranial hemorrhage, and trauma.

 TXA Matters

Tranexamic acid (TXA; brand names Cyklokapron and Lysteda) is a synthetic derivative of lysine that reversibly attaches to lysine binding sites on plasminogen, preventing its activation to plasmin. Since plasmin breaks down fibrin clots, TXA prevents clot breakdown, which can maintain (not create) clots and reduce bleeding. Also, the coagulation and inflammatory cascades overlap (eg, plasmin activates complement), so TXA may have an anti-inflammatory mechanism as well.

 Using TXA for Traumatic Bleeds

Bottom Line For Emergency Physicians: Give intravenous TXA in trauma with confirmed or suspected major hemorrhage. Earlier treatment is better, and use 3 hours after injury may not be effective and may increase harm. Consider topical TXA for epistaxis or minor bleeding from dental extractions or lacerations. Epistaxis: Cotton pledget soaked in the injectable form of TXA (500 mg in 5 mL) is inserted into affected nostril. TXA mouthwash can be used for bleeding after dental procedures. If the mouthwash is not available, a paste can be made by crushing 3 TXA tablets and mixing with small aliquots of sterile water, and applying to sites of minor bleeding, such as dental extraction sites,

Articles of Interest

Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis

TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.

Antifibrinolytics (such as tranexamic acid) for treatment of heavy menstrual bleeding

Antifibrinolytic treatment (such as TXA) appears effective for treating HMB compared to placebo, NSAIDs, oral luteal progestogens, ethamsylate, or herbal remedies, but may be less effective than LIUS. There were too few data for most comparisons to determine whether antifibrinolytics were associated with increased risk of adverse events, and most studies did not specifically include thromboembolism as an outcome.

Does earlier TXA save lives?

TXA is a medication that has raised a fair degree of controversy, mostly in the US, and whilst the current evidence base is not perfect (Ed – there is no such thing as a perfect evidence base outside of n=1 trials), we believe that until new evidence arives to the contrary then we should be giving it to our major trauma patients.

Is TXA a Lifesaving Drug That’s Too Cheap to Bother Using?

TXA is a generic drug that’s been around for decades, and in fact is sold over-the-counter in Europe and Japan for heavy menses. Delivered via IV to trauma patients, it’s been found to be lifesaving, with no dangerous side effects. It has the potential to save thousands of lives a year across the United States. And yet, very few EMS systems have incorporated it into their protocols.

It’s Time for Tranexamic Acid (TXA) in Massive Hemorrhage

In patients with massive bleeding from trauma or post-partum hemorrhage, giving TXA as soon as bleeding is suspected, reduces mortality from bleeding.

Tranexamic Acid (TXA) for Everything that Bleeds?

Fast forward to today and we are finding all kinds of uses for TXA other than trauma including post-partum hemorrhage, epistaxis, hemoptysis, gastrointestinal hemorrhage, and many more.

Tranexamic Acid for Hemoptysis: A Review

Overall, TXA is an underrecognized treatment that may have temporizing value in managing patients with nonmassive hemoptysis. In the context that the available literature is sparse, large, well-designed clinical trials are needed to advance understanding of the role of TXA in hemoptysis.

Tranexamic Acid Time to Treatment

The use of tranexamic acid(or TXA) has become widespread in the case of major trauma and bleeding and post partum haemorrhage. This time we discuss a recent paper that asks us if giving it within 3 hours is enough, or whether we need to be even more specific regarding its urgency of administration in order to save lives from bleeding.

Resources

Lie in the Fastlane

Anti-fibrinolytic agent with many uses in preventing haemorrhage that rose to prominence following the CRASH-2 study showing a mortality benefit in trauma patients

MedicineNet

Tranexamic acid blocks the action of plasmin on fibrin and thereby prevents the breakdown of fibrin.This leads to stabilization and preservation of fibrin in blood clots...

StatPearls

Intravenous TXA is commonly used in severely bleeding patients requiring massive transfusion protocols (MTP) or when hyper-fibrinolysis is demonstrated. The most frequent sign is in trauma patients but may be utilized in any patient at significant risk of hemorrhage.