TXA: NOT JUST A ONE TRICK PONY TERRY MCGOVERN DO, MPH VITUITY, ST JOHN S REGIONAL MEDICAL CENTER, OXNARD, CA
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1 TXA: NOT JUST A ONE TRICK PONY TERRY MCGOVERN DO, MPH VITUITY, ST JOHN S REGIONAL MEDICAL CENTER, OXNARD, CA
2 DISCLOSURES I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity I do intend to discuss an unapproved/investigative use of a commercial product in my presentation
3 OBJECTIVES Discuss alternative uses of TXA Identify the clinical settings most suitable for off label TXA usage Assemble a treatment plan to utilize in practice
4
5 TRANEXAMIC ACID (TXA)
6 WHERE ELSE CAN WE USE TXA? GI bleeds Postpartum hemorrhage Post-tPA bleeds Epistaxis Hyphemas Dental Bleeding
7 TXA FOR GI BLEEDS Outcomes RR CI Significance Quality (GRADE) Mortality Yes Moderate Rebleeding No Low Thromboembolic events No Moderate
8 APPROACHES OF DELIVERING TXA TO GI BLEEDS TOPICAL TXA AS A NOVEL TREATMENT FOR BLEEDING PEPTIC ULCERS: A RCT 120 kids (1 mo 15 yo) randomized to receive either topical TXA (500mg via EGD) or standard care of injectable epinephrine in 4 sites surrounding the ulcer No difference in LOS, emergent surgery, blood transfusions. Control group required more repeat endoscopies COMPARISON OF IV TXA W/WO TOPICAL TXA VS PLACEBO IN URGENT ENDOSCOPY RATE FOR ACUTE UGIB: A DOUBLE BLIND RCT 410 adult patients randomized to groups A, B or C. No significant difference in mortality, rebleeding, transfusion, intervention at endoscopy Higher proportion of group C (placebo) required urgent endoscopy (<6hr)
9
10 THE WOMAN TRIAL WORLD MATERNAL ANTIFIBRINOLYTIC TRIAL
11 EPISTAXIS
12 TXA vs Epi/Lido 124 Patients with uncomplicated anterior bleeds 500mg/5ml TXA vs Epi(1:100,000) Lido (2%) Hemostasis < 10 min Lido/Epi TXA Difference 29% 73% 44% LOS < 2hr 13% 97% 84% 24hr recurrence 10% 5% -5%
13 TRAUMATIC HYPHEMA 2013 Cochrane Review
14 DENTAL BLEEDS Most data we have for TXA Mostly in dental / operative literature 2017 SR/Meta-Analysis 5 RCTs RR: 0.13 ( ) p=0.01 TXA protective effect in A/C patients Recent 2018 RCT Tooth extractions on warfarin Time to hemostasis significantly shorter (p<0.001)
15
16
17 QUESTIONS?
18 REFERENCES Rafeey M, et al. Topical TXA as a novel treatment for bleeding peptic ulcers: A RCT. Afr J Paediatri Surg ;13(1):9-13. Bennett C, et al. TXA for upper gastrointestinal bleeding (Review). Cochrane database of systematic reviews Art. No.: CD Tavakoli N, et al. Comparison of the efficacy of intravenous tranexamic acid with and without topical administration versus placebo in urgent endoscopy rate for acute gastrointestinal bleeding: A double-blind randomized controlled trial. UEG J. 2018;6(1):46-54 Shakur H, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum hemorrhage (WOMAN): an international, randomized, double-blind, placebo-controlled trial. Lancet. 2017;389(10084): Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013; 31: Zahed R, et al. Topical TXA compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: a randomized controlled trial. Acad Emerg Med. 2018;25(3): Gharaibe A, et al. Medical interventions for traumatic hyphema. Cochrane database for systematic reviews DOI: / CD pub3 Vasconcellos S, et al. Topical application of TXA in anticoagulated patients undergoing minor oral surgery: A systematic review and meta-analysis of randomized controlled trials. Journal of Cranio-maxillofacial surgery. 2017;45(1): Bellam B, et al. Efficacy of tranexamic acid in haemoptysis: A randomized, controlled pilot study. Pulm Pharmacol Ther. 2016; 40:80-3. French KF, et al. Treatment of intracerebral hemorrhage with tranexamic acid after thrombolysis with tissue plasminogen activator. Neurocritical care, 2012; 17(1): Hankerson M, et al. Nebulized tranexamic acid as a noninvasive therapy for cancer-related hemoptysis. Joural of palliative medicine. 2015;18(12)
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