Stopping the flow: Tranexamic acid as an adjunct to anterior epistaxis management - An invited commentary

Anterior epistaxis is one of the most common emergencies encountered by otolaryngologists and is usually managed with anterior nasal pressure, topical vasoconstrictors, anesthetics, cautery, and nasal packing. While traditional methods are often effective, they can cause discomfort and can result in recurrent bleeding and repeat emergency department visits. Tranexamic acid (TXA) is a synthetic lysine analog developed in the 1960s as an antifibrinolytic agent and has become an emerging adjunct in the acute management of epistaxis. By inhibiting fibrinolysis locally at the bleeding site, topical TXA offers rapid hemostasis without the discomfort and complications of traditional packing. Evidence from randomized controlled trials and meta-analyses shows that topical TXA improves acute bleeding control, reduces rebleeding, and shortens emergency department stays compared to packing, especially in patients on antiplatelet or anticoagulant therapy. TXA preparations typically include 500 mg in 5 mL applied to a pledget or sponge and put in place for 10-15 min before reassessment of bleeding. Advantages include improved patient comfort, reduced need for follow-up removal, and minimal systemic absorption. Precautions include avoidance in patients with active thromboembolic disease, though safety data are favorable overall. The implementation of topical TXA in clinical protocols demonstrates a movement toward less invasive evidence-based treatments which provide better patient outcomes without compromising effectiveness. The emergency care team along with otolaryngologists can use TXA as a safe and effective treatment for epistaxis management. Incorporating TXA into treatment protocols has the potential to reduce the need for packing and follow-up visits.