TXA: Who uses it and for what and how?

[RustedFox]

It's all in the title. We have a lot of it now. Interested to hear things.

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[Dr Mantis Toboggan]

It's all in the title. We have a lot of it now. Interested to hear things.

Had a baaaad food anaphylaxis with tongue angioedema and I called anesthesia for a Fiber-optic tube. He was happy to come in but suggested TXA 1000 mg. I was all set to give it but the epi drip finally kicked in and she improved and didn’t get it or the tube.

Anyone else use it in this scenario?

 

[RustedFox]

Had a baaaad food anaphylaxis with tongue angioedema and I called anesthesia for a Fiber-optic tube. He was happy to come in but suggested TXA 1000 mg. I was all set to give it but the epi drip finally kicked in and she improved and didn’t get it or the tube.

Anyone else use it in this scenario?

See; I had heard something of this sort - but didn't really believe my ears and I was too busy at the time to research it.

 

[BoardingDoc]

Dental bleeding on Coumadin. Txa soaked gauze packed into the bleeding area.

 

[Jabbed]

“TXA: The Miracle drug with mostly negative trial results ”

Had a baaaad food anaphylaxis with tongue angioedema and I called anesthesia for a Fiber-optic tube. He was happy to come in but suggested TXA 1000 mg. I was all set to give it but the epi drip finally kicked in and she improved and didn’t get it or the tube.

Anyone else use it in this scenario?

I’ve used it for bradykinin-mediated angioedema. I’m not sure what the rationale would be for allergic angioedema as the whole role of TXA is to decrease bradykinin formation.

Dental bleeding on Coumadin. Txa soaked gauze packed into the bleeding area.

Direct mucosal application is really the only time that I’ve thought it’s actually worked.

 

[emergentmd]

It's all in the title. We have a lot of it now. Interested to hear things.

I used it for a pt who was pseudo-allergic to IV contrast and prevented SJS.

 

[Siggy]

Post partum bleeding (WOMAN trial) and as a last ditch for general post op patients who are bleeding. Technically tramatic bleeds should get them (CRASH-3 trial), but by the time the ICU gets involved with the LOL-FDGB* with a brain bleed it's already past the 3 hour window. Since my hospitals aren't trauma centers, I don't think the EM physician is thinking about it.

I'm always tempted to do it for GI bleeds, but the trial for that was negative. It seems to work well with the other bleeds... but it's always hard to tell when a medication works vs tincture of time.

Theoretically TEG/ROTEM could tell us when to use it, but no place I've been at has them.


*Little Old Lady, Fall Down Go Boom

 

[HemorrhagicShock]

Nebulized for hemoptysis

 

[thegenius]

“TXA: The Miracle drug with mostly negative trial results ”

Ain't that the truth!!

It's like gabapentin. A commonly used and largely useless drug.

 

[bravotwozero]

I've used it for ace inhibitor angioedema, and epistaxis. Did diddly squat for the patient.

 

[FiremedicMike]

See; I had heard something of this sort - but didn't really believe my ears and I was too busy at the time to research it.

Pharmacist ran us through the clotting cascade and explained how TXA can help in lisonopril angioedema, I’ve seen it done once for that as well.

We also use it for severe GI bleeding

 

[Dr Mantis Toboggan]

I used it for a pt who was pseudo-allergic to IV contrast and prevented SJS.

Too soon.

 

[Siggy]

Ain't that the truth!!

It's like gabapentin. A commonly used and largely useless drug.

You spelled Colace wrong.

 

[Jabbed]

Post partum bleeding (WOMAN trial) and as a last ditch for general post op patients who are bleeding. Technically tramatic bleeds should get them (CRASH-3 trial), but by the time the ICU gets involved with the LOL-FDGB* with a brain bleed it's already past the 3 hour window. Since my hospitals aren't trauma centers, I don't think the EM physician is thinking about it.

I'm always tempted to do it for GI bleeds, but the trial for that was negative. It seems to work well with the other bleeds... but it's always hard to tell when a medication works vs tincture of time.

Theoretically TEG/ROTEM could tell us when to use it, but no place I've been at has them.


*Little Old Lady, Fall Down Go Boom

We also use it for severe GI bleeding

That’s the rub though. Even though we use it because we believe, the trial data just isn’t convincing.

• HALT-IT: No benefit in mortality or RBC transfusion in GI bleeding with a 4000 mg protocol (so do you think that the commonly given dose of 1000 mg is doing anything?)
• WOMAN: Slight benefit in mortality due to bleeding, but overall mortality remains the same. So instead of bleeding to death, you ______ to death. It’s a fragile result and unlikely to be replicated given that it was a secondary outcome and the CI already crossed 1.0. The primary outcome (overall mortality), was negative.
• CRASH-3: Similar to above. Positive outcome came from a subgroup analysis and the statistics are weaker than they appear.

The one thing that’s generally consistent though is that TXA is safe to give in 1000-2000 mg doses. So you’re relatively justified using it for anything bleeding-related. Just don’t expect it to save the day.

 

[FiremedicMike]

That’s the rub though. Even though we use it because we believe, the trial data just isn’t convincing.

• HALT-IT: No benefit in mortality or RBC transfusion in GI bleeding with a 4000 mg protocol (so do you think that the commonly given dose of 1000 mg is doing anything?)
• WOMAN: Slight benefit in mortality due to bleeding, but overall mortality remains the same. So instead of bleeding to death, you ______ to death. It’s a fragile result and unlikely to be replicated given that it was a secondary outcome and the CI already crossed 1.0. The primary outcome (overall mortality), was negative.
• CRASH-3: Similar to above. Positive outcome came from a subgroup analysis and the statistics are weaker than they appear.

The one thing that’s generally consistent though is that TXA is safe to give in 1000-2000 mg doses. So you’re relatively justified using it for anything bleeding-related. Just don’t expect it to save the day.

It's been literally years since I read the studies. I was fairly up to date on their conclusions at the time, but honestly had forgotten the meat of their results.

Strictly anecdotal with an N=1, but the last GI bleed we gave it to slowed his bleeding down significantly before being sent up to the floor..

Thanks for putting that back on my radar.. I'll review them again this afternoon.

 

[Janders]

Its analogous to giving TPA and the patient “suddenly is neuro intact!”. Did the TPA do it, or was it a TIA already?

Personally I do like it for topical / mucosal bleeding that won’t stop oozing. Certainly low risk, cheap, and it seems to help things like dental extractions, etc. Also its a reasonable kitchen sink med for something like a dying posterior epistaxis (I had this one case…) or nebulized for deeper tracheal bleeding as you have few options in many places.

I have tried it for random angio-edema. I’ve never seen it obviously do anything. Some of the other docs would try it too, and pharmacy got irritated, sent it to P&T, and asked for any evidence it works b/c its off-label clearly. There is very little evidence it works for angio-edema would be my overall lit review on that topic.

I don’t work in a trauma center, but if we get a drop off or EMS divert or poor EMS triage patient who is literally DYING of trauma and I have to xfer them stat to a real trauma center, I typically give it based on MATTERs/CRASH-2 understanding it may not work but doesn’t harm and figure its a bit analogous to transporting wounded soldiers…

CRASH-3 has not changed my or local NSURG practice patterns; should it have?

I would consider it in a crash delivery post-partum hemorrhage (we don’t have OB so we’d be trying to transfer that) for similar reasons to the above.

I was optimistic but after the trials have NOT used it for GI bleeds.

 

[turkeyjerky]

I've used it once or twice for hemoptysis and it seemed to work pretty well. I try not to get carried away w/ anecodotal results, but it was impressive enough to make me a believer for that indication. Dental/oral bleeding is a definite yes for me, I send patients home w/ an rx for it to use too (tell them to crush it and make a paste). Epistaxis is a weird one, I stopped using it after the negative data came out, but I seem to have lost my mojo for this recently so I might go back to it.

I give it for bradykinin mediated angioedema, often along w/ FFP, to patients I think might progress to needing a tube but aren't there yet. I don't believe anyone who ever "swears" by anything for this condition, it's too unpredictable and too heterogeneous a condition to take any anecdotal experience at face value. But I don't particularly like telling patients that I'm going to do nothing and check back in on them in 30 minutes and decide whether to intubate or not. My rule--if they hit the call light twice, they get tubed)

GI bleed's a no. Trauma's a yes. (I have to believe that all the criticism about Crash-2 was driven by people getting money from Big Factor VIIa. Agree, however, that Crash-3 was unimpressive).

I doubt its effective as a 'last ditch' for anything, likely needs to be given early to make a diff.

 

[lucid_leprechaun]

If you are going to do the other bull**** for ACE inhibitor induced angioedema that you are considering intubating, I would give a gram of TXA. I have seen patients dramatically improve after 1-2 hrs. The literature is there but mostly case series. Certainly better than treating like an allergy.

 

[RustedFox]

If you are going to do the other bull**** for ACE inhibitor induced angioedema that you are considering intubating, I would give a gram of TXA. I have seen patients dramatically improve after 1-2 hrs. The literature is there but mostly case series. Certainly better than treating like an allergy.

I presume the other BS is Medrol/Benadryl/Pepcid/FFP.

I worked at one shop 10 years ago that kept a singular box of Kalbitor for one particular patient that knew that he had HANE. I never saw him, so I found it enigmatic enough to take notice.

 

[WilcoWorld]

I used it for a pt who was pseudo-allergic to IV contrast and prevented SJS.

That's because you were trained by Bruce Janiak so you consulted the allergy/immunologist from the ED, based purely on intuition, before a reaction could even develop.

 

[WilcoWorld]

Ain't that the truth!!

It's like gabapentin. A commonly used and largely useless drug.

Oh man, don't get me started on gabapentin, or tramadol...

 

[Radetzky]

I give it for bleeding of any cause, we have enough data to know the concern of worsening clotting is unfounded. So I just give it and have stopped worrying about whether it actually works or not.

 

[Jabbed]

Ain't that the truth!!

It's like gabapentin. A commonly used and largely useless drug.

Oh man, don't get me started on gabapentin, or tramadol...

Did I drink the Kool-Aid?? I use gabapentin all the time for neuropathic pain. If anything, I feel that people just don’t titrate it high enough.

 

[WilcoWorld]

Did I drink the Kool-Aid?? I use gabapentin all the time for neuropathic pain. If anything, I feel that people just don’t titrate it high enough.

Doses over 1800mg/d have never been found to do anything other than increase side effects. Gabapentin has shown benefit for diabetic neuropathy, and maybe some forms of pruritis. On the other hand, gabapentin causes delirium, somnolence, and peripheral edema in a lot of patients without providing significant pain relief - just adding to pill burden. With chemotherapy induced neuropathy and other types of low back & leg pain other agents (TCA's, SNRI's) have far better efficacy evidence.

In conclusion: it's reasonable to treat diabetic peripheral neuropathy (and some forms of pruritis) with gabapentin at doses no higher than 1800mg/d. Beyond that, it's likely more burden than benefit.

What does an ER Doc do with this? Not much, other than scanning the med list of your patients presenting with AMS or peripheral edema for gabapentin. If it's found, consider asking "has the gabapentin helped?"

 

[TooMuchResearch]

Bleeding dental extraction site.
Nebulized for post-tonsillectomy hemorrhage.
In the nose for epistaxis.
The bleeding stopped, but I can't tell you if the txa did it or not.

 

[thegenius]

Doses over 1800mg/d have never been found to do anything other than increase side effects. Gabapentin has shown benefit for diabetic neuropathy, and maybe some forms of pruritis. On the other hand, gabapentin causes delirium, somnolence, and peripheral edema in a lot of patients without providing significant pain relief - just adding to pill burden. With chemotherapy induced neuropathy and other types of low back & leg pain other agents (TCA's, SNRI's) have far better efficacy evidence.

In conclusion: it's reasonable to treat diabetic peripheral neuropathy (and some forms of pruritis) with gabapentin at doses no higher than 1800mg/d. Beyond that, it's likely more burden than benefit.

What does an ER Doc do with this? Not much, other than scanning the med list of your patients presenting with AMS or peripheral edema for gabapentin. If it's found, consider asking "has the gabapentin helped?"

I thought gabapentin was also approved for post-herpetic neuralgia. I knew about diabetic neuropathy. I thought it was only approved for two things, despite docs providing it for everything out there.

 

[MechEDoc]

TXA for nosebleeds. Sometimes for trauma (rare). Vaginal bleeding (non-hormonal and ACOG recommended), PO Rx and d/c.

 

[Janders]

Yes I do also use PO for vaginal bleeding in some patients!

 

[RustedFox]

TXA for nosebleeds. Sometimes for trauma (rare). Vaginal bleeding (non-hormonal and ACOG recommended), PO Rx and d/c.

Let me hear more about this PO TXA for DUB.
I rarely see reproductive age females.

 

[Rekt]

I've used it for all kinds of things. Epistaxis. Oral bleeds. Fistulas. Trauma patients. Angioedema (many times), post-tonsillectomy, etc and I feel like it never does anything. Super hyped up in the EM community but feels useless.

 

[sloh]

Did I drink the Kool-Aid?? I use gabapentin all the time for neuropathic pain. If anything, I feel that people just don’t titrate it high enough.

PM&R here. You did drink the kool-aid.

"A 2016 double-blind RCT (N = 108) investigated gabapentin as a treatment for chronic low back pain with and without a radicular component. Participants were adults who had at least a six-month history of daily back pain, primarily in the lumbar region, that affected at least two aspects of everyday life, and a pain score of 2 or greater on a 10-point scale. The gabapentin arm was a forced titration design with a daily target of 3,600 mg divided into three doses. The placebo group also up-titrated the placebo pills. The primary outcome was pain intensity (as measured by the Descriptor Differential Scale of Pain Intensity); secondary outcomes included mood (as measured by the Beck Depression Inventory-II) and everyday function (as measured by the Oswestry Disability Index). At 12 weeks there was a significant decrease from baseline in overall pain scores for both groups (P < .0001) but no significant difference between the groups (P = .423). There was no difference between radicular and nonradicular pain, and no difference in pain scores based on plasma levels of gabapentin. There was an overall significant decrease in depressive mood symptoms in both groups (P < .0001) but no significant difference between the groups (P = .519). There was also no significant difference in functionality between groups (P = .804)."

"For pregabalin, FDA-approved indications related to pain are limited to postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy or spinal cord injury, and fibromyalgia. Despite these limited indications, gabapentin and pregabalin are widely prescribed off-label for various other pain syndromes.

Clinicians who prescribe gabapentinoids off-label for pain should be aware of the limited evidence and should acknowledge to patients that potential benefits are uncertain for most off-label uses."

A Clinical Overview of Off-label Use of Gabapentinoid Drugs

This Special Communication summarizes the limited published evidence to support off-label gabapentinoid uses, describes clinical cases in which off-label use is problematic, and notes how review articles and guidelines tend to overstate gabapentinoid effectiveness.

jamanetwork.com

Gabapentin for Treatment of Radicular Low Back Pain

Gabapentin is not effective for the treatment of radicular low back pain and is associated with adverse effects.

www.aafp.org

 

[Janders]

Let me hear more about this PO TXA for DUB.
I rarely see reproductive age females.

So for the standard “my periods are insanely heavy / long, I’m becoming anemic, I saw a GYN once but I hated the nexplanon so I go rid of that and didn’t go back, my PCP just said come here and get a transfusion” vaginal bleeds I see—>

(Aside, soapbox time. The standard care of these young / minority / lower-middle class women get for a truly troublesome chronic problem by the generic PCP clinics they go to seems to be abysmal. Rarely try OCPs / IUDs. Rarely properly Rx iron. Given a shot of depot or an implant which often has significant side effects so they don’t continue and don’t trust the clinic and stop going. Often just shrug and sent to ED for IV iron (lol) or transfusion. Universally I’ve found these women very interested in their own health, and very interested in seeing a GYN to really work through the reason they have severe vaginal bleeding and the various treatment options. They totally understand there is trial and error and we might need to try a couple things to get this right. It strikes me as one of the most obvious misogynistic / classist issues in my everyday work life)

VItals OK, Hg>7, not actively fire-hosing:
Patient gets to pick…
(1) Do nothing, see if nature helps
(2) IBUPROFEN Rx strength round the clock for a week might actually help your bleeding and is gentle!
(3) Do you want to start oral birth control? I’ll write you for it. (Can even start as a taper’d dose pack with real bad bleeding).
(4) Don’t want OCP for bad experience / reasons, but want something more than NSAID? Lets try TXA
(5) You should take oral iron every-OTHER day. And see a GYN interested in helping you. Other options like IUD, endometrial ablation, hysterectomy, etc etc exist!

Now the brand name FDA approved TXA for vaginal bleeding is Lysteda. You dose it 1300mg 3x a day for 5 days. The studies are that it basically cuts bleeding in half, it improves thing like social outcomes (not afraid to leave the house b/c you bled through everything), and by 2-3 cycles 4/5 women find it helpful. Probably don’t give it WITH OCP due to theoretical clotting risk, and I wouldn’t if they had DVT and were NOT on anticoag, though it might actually be safe. You can use other formulations, you basically need 3-4gm a day for 4-5 days.

ACOG has a solid summary for non-pregnant vaginal bleeding dx/management that has significant overlap with our practice, it has some links to primary evidence etc…

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

www.acog.org

 

[Dred Pirate]

most people touched on this - a drug that works for everything, but has very little evidence that it helps much.

1. Mucosal bleeding (epistaxis, gum post tooth extraction, etc). Soak some gauze in it (or aminocaproic acid if shortage). Kinda works, sometimes, maybe.
2. Post partum bleeding (my wife got a gram of this when she hemorrhaged) but I think the vaginal packing probably did more, but what do I know- I am not an OB.
3. Intra-op cardiac surgery (replaced 5 grams aminocaproic acid)
4.Pre-op ortho surgery
5. ACE-I angioedema - I recommended it once as the doc wanted to do something and originally ordered Kalbitor, and when I showed him there is no evidence it works and costs almost $20k, he was more than willing to try a $20 drug instead - pt had been experiencing symptoms for 12 hours and at that moment in time was in no danger of needed tubed.

 

[gutonc]

most people touched on this - a drug that works for everything, but has very little evidence that it helps much.

Where I work, marijuana fits this description.

 

[CajunMedic]

I'm like everyone else:
1. Nosebleeds, mucosal bleeds, The 1 patient with a lat flap oral reconstruction that fell off (may have talked about that sphincter clenching experience on here already)
2. Topically on a pledget for skin tears, etc. Worked better when we had the tablets to crush
3. Sent someone home on it a couple of times for DUB with OB's input
4. Trauma a la MATTERS/CRASH 2

 

[Tenk]

Used it in nasal bleeds by soaking gauze with that and lidocaine with epi many times. Used it once for bad angioedema.

Also, I hate nosebleeds.

 

[RustedFox]

Used it in nasal bleeds by soaking gauze with that and lidocaine with epi many times. Used it once for bad angioedema.

Also, I hate nosebleeds.

1. I also hate nosebleeds.
2. Change your profile pic back to pepe. Lol.

 

[turkeyjerky]

VItals OK, Hg>7, not actively fire-hosing:

I don't want to take away from your otherwise excellent post, with which I almost completely agree, but I'd replace 7 w/ 5 (or 4...)

Also, I do see a role for IV iron in these patients.

 

[Tenk]

1. I also hate nosebleeds.
2. Change your profile pic back to pepe. Lol.

No, need Shia LaBeouf to carry EM out of this mess.

 

[The Knife & Gun Club]

I was actually one of the authors on a decently large study looking at using TXA for unstable pelvic ring fractures in trauma back in 2018.

I combed that data set with an insane amount of detail. It certainly seemed to work reviewing the charts, and the orthopods swore by it. But whenever we tried to analyze the data it was way too weak to get a clear effect. Basically what we came back with was that you can slightly decrease the transfusion rates and EBL in the OR if you give it. Not really helpful to EM peeps at all, and in fact it seemed to work better if you gave it in the OR right before surgery.

The more interesting thing from my point of view was that it didn’t seem to increase risk of DVTs or PEs at all, which in that population is super common.

So the takeaway I had is that it’s fine to try it if you want but it doesn’t seem to do much of anything, unless you’re worried about your orthopods EBL.

 

[GassYous]

Why wouldn't you use something soaked with afrin or phenylephrine for the nosebleed

 

[thegenius]

Why wouldn't you use something soaked with afrin or phenylephrine for the nosebleed

I would...these are better options than TXA. TXA is only good for capillary oozing (which the nose could be in some cases) but it's useless for medium sized and up arteries. probably no good for even small arteries.

TXA is largely a lousy drug with few side effects.

 

[Dred Pirate]

Not really helpful to EM peeps at all, and in fact it seemed to work better if you gave it in the OR right before surgery.

Many of our orthopods do it this way - and one does a slow transfusion during surgery

 

[Janders]

I don't want to take away from your otherwise excellent post, with which I almost completely agree, but I'd replace 7 w/ 5 (or 4...)

Also, I do see a role for IV iron in these patients.

Oh I think we agree, I don’ mean I transfuse at Hg7, just that around there I start to have different thoughts with these patients, including as you mentioned IV iron, potentially transfusion depending on age / pace of bleeding / exact Hg, doubling up on insisting they follow up with someone, etc.

 

[TooMuchResearch]

If I start certifying people for marijuana from the ED, I'll probably get some emails or phone calls I don't want.