Know When to Consider Using Topical or Nebulized Tranexamic Acid

You'll see tranexamic acid used topically or via addition to typical routes, such as IV in trauma or postpartum hemorrhage.

Topical tranexamic acid is gaining traction for epistaxis.

Inserting a cotton pledget soaked in injectable tranexamic acid seems to decrease bleeding time by about 5 minutes and increase ED discharges at 2 hours compared to topical epinephrine and lidocaine...even in patients taking antiplatelets.

And limited evidence suggests there's no increase in thrombotic events.

Consider tranexamic acid for epistaxis if pressure and oxymetazoline (Afrin, etc) aren't enough. Oxymetazoline is about $2/bottle...versus about $20/vial for tranexamic acid. The two haven't been directly compared.

Or think about using an atomizer to spray tranexamic acid...followed by external compression for 15 minutes. This works as well as nasal packing...and might be more comfortable.

Nebulized tranexamic acid is the latest option for hemoptysis due to lung cancer, bronchiectasis, infection, etc.

It seems to increase bleeding resolution and decrease length of stay by about 2 days versus placebo.

Consider adding it for NONmassive hemoptysis, such as patients with no airway obstruction or less than a cup of blood in 24 hours.

Work with respiratory therapy to create a tranexamic acid nebulizer protocol.

Verify your IT team creates separate EHR entries for topical and nebulized routes...such as "tranexamic nasal topical solution."

Get our chart, Topical or Nebulized Tranexamic Acid, for more on dosing and safety.

Key References

  • Ann Emerg Med 2019;74(1):72-8
  • Acad Emerg Med 2018;25(3):261-66
  • Chest 2018;154(6):1379-84
  • Ann Pharmacother 2019;53(6):652-7
  • Medication pricing by Elsevier, accessed Jul 2019
Hospital Prescriber's Letter. August 2019, No. 350819

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