TXA

[thegenius]

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Any of you guys and gals giving TXA for
- uterine bleeding
- epistaxis
- GI bleeding
- any other bleeding

Better yet...any of you guys and gals writing scripts for TXA?

Someone in my family was having heaving menstrual bleeding for months and her Gynecologist prescribed TXA. She asked me whether it was safe to take and honestly I didn't know much about it overall beside it's use in bleeding in major trauma.

 

[TooMuchResearch]

Yes, I've used it for all those things (topical for epistaxis). Haven't heard about Rx for vaginal bleeding... not something I would do.

Any of you guys and gals giving TXA for
- uterine bleeding
- epistaxis
- GI bleeding
- any other bleeding

Better yet...any of you guys and gals writing scripts for TXA?

Someone in my family was having heaving menstrual bleeding for months and her Gynecologist prescribed TXA. She asked me whether it was safe to take and honestly I didn't know much about it overall beside it's use in bleeding in major trauma.

 

[zurned]

Any of you guys and gals giving TXA for
- uterine bleeding
- epistaxis
- GI bleeding
- any other bleeding

Better yet...any of you guys and gals writing scripts for TXA?

Someone in my family was having heaving menstrual bleeding for months and her Gynecologist prescribed TXA. She asked me whether it was safe to take and honestly I didn't know much about it overall beside it's use in bleeding in major trauma.

Yes, I recently prescribed it for someone with uterine bleeding due to a choriocarcinoma/molar pregnancy. I called her gynecologist and that is what he recommended (for 5 days). Patient was suppose to start chemotherapy in a week so it was to temporize the bleeding until then I think. The dose he suggested was exactly what was listed on uptodate.

 

[BoardingDoc]

Any of you guys and gals giving TXA for
- uterine bleeding
- epistaxis
- GI bleeding
- any other bleeding

Better yet...any of you guys and gals writing scripts for TXA?

Someone in my family was having heaving menstrual bleeding for months and her Gynecologist prescribed TXA. She asked me whether it was safe to take and honestly I didn't know much about it overall beside it's use in bleeding in major trauma.

I use it for epistaxis or for intraoral bleeding in a patient on coumadin. Just soak some gauze in it and pack the affected area for 15-30 min. I haven't used it for any other indication outside of major trauma when I was a resident and I have honestly never remotely considered sending a patient home with it. Not saying it's wrong, I just have 0 familiarity with it and have never seen anyone prescribe it.

 

[DrDrummer]

Yes. Used it yesterday for post-tonsillectomy bleeding prior to OR, have prescribed it for menorrhagia (don’t mix with OCPs), and for bleeding from malignancies (topical paste made from Lysteda tablets). It’s a great drug.

 

[GonnaBeADoc2222]

In addition to epistaxis you can use for post dental extraction bleeding (soak gauze and have them bite down)... You can also nebulize for post tonsillectomy bleeds

 

[deleted109597]

Never given an Rx, but never had the opportunity.
I've used it for everything else though.

 

[dchristismi]

TXA is old and cheap and has been used for menometrorrhagia in other countries for decades.

I got a tiny arterial bleed (that I tried unsuccessfully to tie off several times) along the underside of the antihelix to stop with TXA applied to a little pledget of gauze. Guy was 90, and just wanted to put his hearing aids back in. I just wanted him to hold still. How the hell he fell into a chair (it shattered) and lacerated that part of his ear I still don't know. He was on aspirin, and came in covered in blood.

In my inpatient hospice practice, I try to have it in the pyxis if I have a head and neck cancer who is high risk of bleeding who isn't definitely at the end of their life, or anyone with significant hemoptysis (just nebulize it.) I sent a young lady with a nasty pulmonary sarcoma and significant hemopysis home with the IV version and a nebulizer... just in case. She ultimately died of her cancer, but I figured that her little kids would be traumatized forever if she drowned in her own blood at home, and although we have 24/7 response, this is the sort of thing I'd want the family to be able to do in a catastrophe.

There is literature showing that head-and-neck cancer-related terminal hemorrhage doesn't always have to be terminal. If your carotid blows out, you're pretty much out of luck, but if it's a smaller vessel, it might actually stop it. And if it's inside and you can't pack a paste on, nebulizing it works relatively well.

 

[Groove]

Any of you guys and gals giving TXA for
- uterine bleeding
- epistaxis
- GI bleeding
- any other bleeding

Better yet...any of you guys and gals writing scripts for TXA?

Someone in my family was having heaving menstrual bleeding for months and her Gynecologist prescribed TXA. She asked me whether it was safe to take and honestly I didn't know much about it overall beside it's use in bleeding in major trauma.

1) No
2) Yes (topical)
3) No, but I've considered adding it to my hail mary interventions in the really bad ones despite little research to support using it routinely in GI bleeds.
4) Trauma, but I haven't had to give TXA for trauma since residency. I'll nebulize it with the albuterol for the bad hemoptysis pt's. (You can mix with albuterol.)

That's about it. I've never Rx or used it for uterine bleeding though it seems to be supported.

 

[thegenius]

Is the data conclusive, or nearly conclusive, that it doesn't help GI bleeds?

 

[Groove]

Is the data conclusive, or nearly conclusive, that it doesn't help GI bleeds?

For the moment, nobody really knows until the HALT-IT trial is completed. That should put the issue to rest (hopefully). The best we have at the moment is a Cochrane meta-analysis from 2014 that says the following:

(2) The most recent Cochrane meta-analysis of TXA in upper gastrointestinal bleeding from 2014 found no increase in thromboembolic events.(3) This might suggest that in a haemodynamically unstable patient with an upper gastrointestinal haemorrhage, the use of TXA might not be inappropriate.
The HALT-IT trial ( ISRCTN 11225767) is currently recruiting patients and hopefully this study will conclusively settle the matter of the safety of TXA in acute upper gastrointestinal haemorrhage.(4)

Tranexamic acid — Tranexamic acid is an antifibrinolytic agent that has been studied in patients with upper GI bleeding. A meta-analysis that included eight randomized trials of tranexamic acid in patients with upper GI bleeding found a benefit with regard to mortality but not with regard to bleeding, surgery, or transfusion requirements [52]. When only studies that used antiulcer drugs and/or endoscopic therapy were included, there was no beneficial effect. This suggests that there is no role for tranexamic acid in the treatment of upper GI bleeding, since the current standard of care is to treat patients with proton pump inhibitors and endoscopic therapy (if indicated).

Our study suggests that TXA may be underused in the management of UGIB, and that the utilization rate does not differ significantly between surgical and medical intensivists.

You're unlikely to find a GI that supports routine TXA for GI blending but I really fail to see any harm and until HALT-IT results are available, I still consider it a plausible option for hemodynamically unstable GI bleeds where you've thrown the kitchen sink so to speak.

 

[gamerEMdoc]

If you ever wanted to make a paste out of TXA, using the tablets and some saline or sterile water works pretty well. You can make it as thick or as runny as you need it. It's cheaper than using the IV stuff, and you can apply a thick layer over an area of troublesome bleeding.

Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis

Topical tranexamic acid has been described for surface hemostasis. This trick of the track describes how to create a tranexamic acid paste.

www.aliem.com

 

[Groove]

If you ever wanted to make a paste out of TXA, using the tablets and some saline or sterile water works pretty well. You can make it as thick or as runny as you need it. It's cheaper than using the IV stuff, and you can apply a thick layer over an area of troublesome bleeding.

Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis

Topical tranexamic acid has been described for surface hemostasis. This trick of the track describes how to create a tranexamic acid paste.

www.aliem.com

Will pharmacy send up the mortar and pestle or do I have to get one off Allheart? 😉

 

[thegenius]

That TXA paste is pretty cool.

They should do a study where someone makes a think TXA solution with the consistency of pepto bismol and then swallow it for UGIB. Like swallowing 50 cc of this paste. Coat the entire stomach. Stop the bleeding

 

[gutonc]

For the moment, nobody really knows until the HALT-IT trial is completed. That should put the issue to rest (hopefully). The best we have at the moment is a Cochrane meta-analysis from 2014 that says the following:

(2) The most recent Cochrane meta-analysis of TXA in upper gastrointestinal bleeding from 2014 found no increase in thromboembolic events.(3) This might suggest that in a haemodynamically unstable patient with an upper gastrointestinal haemorrhage, the use of TXA might not be inappropriate.
The HALT-IT trial ( ISRCTN 11225767) is currently recruiting patients and hopefully this study will conclusively settle the matter of the safety of TXA in acute upper gastrointestinal haemorrhage.(4)

Tranexamic acid — Tranexamic acid is an antifibrinolytic agent that has been studied in patients with upper GI bleeding. A meta-analysis that included eight randomized trials of tranexamic acid in patients with upper GI bleeding found a benefit with regard to mortality but not with regard to bleeding, surgery, or transfusion requirements [52]. When only studies that used antiulcer drugs and/or endoscopic therapy were included, there was no beneficial effect. This suggests that there is no role for tranexamic acid in the treatment of upper GI bleeding, since the current standard of care is to treat patients with proton pump inhibitors and endoscopic therapy (if indicated).

Our study suggests that TXA may be underused in the management of UGIB, and that the utilization rate does not differ significantly between surgical and medical intensivists.

You're unlikely to find a GI that supports routine TXA for GI blending but I really fail to see any harm and until HALT-IT results are available, I still consider it a plausible option for hemodynamically unstable GI bleeds where you've thrown the kitchen sink so to speak.

As the hem/onc guy that GI suggests you call next, I say that, if you've already thrown the kitchen sink at them and they're still bleeding, might as well throw in the soap dispenser, sponge and dish rag too.

TXA is cheap and has minimal SEs (most importantly, numerous studies suggesting low/no increased risk of thrombosis). It probably doesn't help a lot of these bleeders, but it might help enough.

 

[Janders]

I've put it on anything topical that bleeds, including using a nasal atomizer or nebulizer

I've also written Rx for oral form for menorrhagia a handful of times (while arranging access to GYN for... definitive management...).

I've NOT given it IV for GI bleed, but if I have another variceal bleed dying while I attempt to arrange transfer, I might...

 

[Old_Mil]

In my inpatient hospice practice, I try to have it in the pyxis if I have a head and neck cancer who is high risk of bleeding who isn't definitely at the end of their life, or anyone with significant hemoptysis (just nebulize it.)

There is literature showing that head-and-neck cancer-related terminal hemorrhage doesn't always have to be terminal. If your carotid blows out, you're pretty much out of luck, but if it's a smaller vessel, it might actually stop it. And if it's inside and you can't pack a paste on, nebulizing it works relatively well.

Read this and just was thinking...in my practice, I don't know that I've ever seen a patient with a head and neck cancer either on their PMH/PSH or related to their CC. Seen pretty much everything else, from blood related to ovarian, uterine, prostate, bone, colon, stomach, lung, brain.

Just thought that this was an odd omission. Anyone else think that as well, or is it just a statistical oddity?

 

[Atlas Shrugged]

Oral TXA (Lysteda) is commonly given for heavier uterine bleeding.

 

[dchristismi]

Read this and just was thinking...in my practice, I don't know that I've ever seen a patient with a head and neck cancer either on their PMH/PSH or related to their CC. Seen pretty much everything else, from blood related to ovarian, uterine, prostate, bone, colon, stomach, lung, brain.

Just thought that this was an odd omission. Anyone else think that as well, or is it just a statistical oddity?

I think they're inherently less common. A quick google search told me that only 3% of all cancers in the US are of head and neck origin - I don't know if that's the actual prevalence, but I also only remember a handful, if that, in the my own EM practice.

I'd guess it's also partly due to the high morbidity and mortality of these cancers... Many of them end up trached as well, so maybe they go back to their meccas if/when they have problems?

 

[turkeyjerky]

As the hem/onc guy that GI suggests you call next, I say that, if you've already thrown the kitchen sink at them and they're still bleeding, might as well throw in the soap dispenser, sponge and dish rag too.

TXA is cheap and has minimal SEs (most importantly, numerous studies suggesting low/no increased risk of thrombosis). It probably doesn't help a lot of these bleeders, but it might help enough.

Thank you for this.

I haven't used TXA for GI bleeders (although I would in the right case, I'm waiting for the aforementioned trial results before incorporating it into standard practice). I do, however, prescribe it semi-regularly for abnormal uterine bleeding. I just don't understand why so many people are hesitant to prescribe a drug w/ minimal, if any, increased risk of VTE, in favor of a class of drugs w/ known increased risks of VTE (while citing the risk of thrombosis as the reason to avoid the former).

 

[southerndoc]

Our mass transfusion protocols includes TXA. Anytime we use it or get uncrossmatched blood, we are prompted to give TXA.

 

[thegenius]

Thank you for this.

I haven't used TXA for GI bleeders (although I would in the right case, I'm waiting for the aforementioned trial results before incorporating it into standard practice). I do, however, prescribe it semi-regularly for abnormal uterine bleeding. I just don't understand why so many people are hesitant to prescribe a drug w/ minimal, if any, increased risk of VTE, in favor of a class of drugs w/ known increased risks of VTE (while citing the risk of thrombosis as the reason to avoid the former).

Probably because OCP is probably better at slowing down uterine / fibroid bleeding vs TXA. I think researchers just need to do a few studies of TXA vs placebo and TXA vs OPC and maybe TXA vs (TXA + OCP) to determine if it's worth doing, and if so - it bring it into play.

 

[p1acebo]

Nebulizer TXA is amazing, saved me one time with a bad post op tonsillectomy bleed.

 

[deleted109597]

Probably because OCP is probably better at slowing down uterine / fibroid bleeding vs TXA. I think researchers just need to do a few studies of TXA vs placebo and TXA vs OPC and maybe TXA vs (TXA + OCP) to determine if it's worth doing, and if so - it bring it into play.

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

www.cochrane.org

 

[deleted109597]

Probably because OCP is probably better at slowing down uterine / fibroid bleeding vs TXA. I think researchers just need to do a few studies of TXA vs placebo and TXA vs OPC and maybe TXA vs (TXA + OCP) to determine if it's worth doing, and if so - it bring it into play.

Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women

www.acog.org

 

[CajunMedic]

If you ever wanted to make a paste out of TXA, using the tablets and some saline or sterile water works pretty well. You can make it as thick or as runny as you need it. It's cheaper than using the IV stuff, and you can apply a thick layer over an area of troublesome bleeding.

Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis

Topical tranexamic acid has been described for surface hemostasis. This trick of the track describes how to create a tranexamic acid paste.

www.aliem.com

Used this yesterday, worked like a charm. Had a pt. come back in still bleeding about 10 hours after being seen for a nasty skin tear. Let it sit for about 30 mins and carefully wiped off what I could without disturbing any new clots. They’ll follow up in the wound clinic in 48 hours.