June 27, 2020

Background: Acute gastrointestinal bleeding (GIB) is a common diagnosis dealt with by emergency clinicians.  Definitive therapy for acute GIB often includes endoscopy or surgery. However, there is a myriad of pharmaceutical options (i.e. PPI, Somatostatin Analogues, Antibiotics, etc.) as well as blood products that may be instituted as part of the acute resuscitation of these patients. The role of tranexamic acid (TXA) in resuscitation of this condition is unknown.

TXA has become one of the darling medications of emergency medicine, with numerous indications, minimal side effect profile and low cost. TXA works by inhibiting blood clot breakdown (i.e. fibrinolysis).  TXA has been shown to decrease death from bleeding in other conditions (Trauma, Postpartum hemorrhage) but there is limited evidence for its use in GIB.  A systematic review and meta-analysis of seven randomized trials with just over 1600 patients [2] showed a reduction in all-cause mortality.  However, the individual trials were small and prone to a myriad of biases making these conclusions hypothesis generating at best.

October 15, 2019

Background: Evidence from the CRASH-2 trial showed an absolute reduction in mortality of 1.5% (NNT = 67) in patients with extracranial bleeding treated with tranexamic acid  (TXA) within 3 hours of injury. However, CRASH-2 did not answer the question of effect on mortality in patients with intracranial hemorrhage (ICH), as these patients were excluded from the trial.  It makes biologic sense that administration of TXA in patients with traumatic brain injury (TBI) might prevent or reduce ICH expansion and thus avert brain herniation and death.  There were two smaller RCTs [2] that showed a reduction in death with TXA in patients with ICH. However, both of these trials were small and considered to be hypothesis generating only. TICH-2 [3] was an international, randomized, double-blind, placebo-controlled phase 3 trial in adults with ICH from acute stroke with ≈2300 patients and showed no difference between groups in functional status at day 90. TICH-2 did show a small improvement in hematoma expansion at day 2 and death by day 7.  Due to the fact that these  findings were secondary outcomes they were also hypothesis generating. All of the above positive findings therefore required confirmation in a larger randomized trial, which has finally arrived…CRASH-3.

March 25, 2019

Background: TXA is a synthetic lysine derivative that binds with the lysine site on plasminogen and inhibits fibrinolysis.  TXA is not a new drug. Studies from the late 1960s and early 1970s have shown reduced bleeding and need for transfusions in many surgical and medical settings.  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.

December 3, 2018

Background: Use of tranexamic acid (TXA), an antifibronlytic medication,  has certainly become popular for numerous indications (i.e. trauma, uterine bleeding, epistaxis).  Patients with hemoptysis, frequently come through EDs, and as an ED healthcare provider, I am unable to provide the definitive therapies of bronchial artery embolization and bronchoscopy for these patients at many of the institutions in which I work.  And, of course, it’s not like I can just put my finger on the bleeder. There is no real effective medical therapy for hemoptysis, other than antibiotics for infection.  I often find myself helpless with these patients as all I can do is transfer them to larger institutions where definitive therapies can be done.  Well hold on…It turns out inhaled TXA may be an option to reduce bleeding in patients with hemoptysis.  Thus far the evidence for this has  only been from small case series.  There have been no prospective studies evaluating nebulized TXAs effectiveness as an inhaled treatment for hemoptysis.  I have certainly used this treatment for post-tonsillectomy bleeding and have at times used it for hemoptysis, with great success, but it would be nice to see some evidence to support this practice.

July 30, 2018

Background: Spontaneous, non-traumatic intracerebral hemorrhage, is one of the only stroke subtypes without a proven treatment. It is not as common as ischemic stroke, representing up to 20% of all strokes, but it accounts for almost half of all stroke deaths worldwide.  Furthermore, about a quarter of intracerebral hemorrhage can be complicated by hematoma expansion which can occur up to 24 hours later and is itself associated with poor outcomes.  There have been only small trials looking at the use of tranexamic acid in this group of patients, until now.  The Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2) trial looked to see if intravenous TXA reduces death and dependence when given within 8 hours of spontaneous ICH.
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