Canadian Pharmacists Journal - May/June 2019 - 170

PRACTiCeTOOL
nostril 3 times daily for 3 to 5 days.19 Mattoo et
al.20 saw even higher rates of epistaxis resolution:
86% and 90% with topical xylometazoline 0.5%
and epinephrine 1:10,000, respectively. These
products were applied by packing the affected
nostril(s) for 30 minutes with cotton packs
soaked in the decongestant solution and are used
in combination with other strategies. In 1 study,20
all cases received silver nitrate cautery following
the decongestant, regardless of bleeding status.
In 2 of the 3 above studies,19,20 treatment was
followed by nasal packing (without any embedded active ingredients) in cases where bleeding
persisted despite the use of decongestants. Topical decongestants are a safe and accessible alternative for outpatients; however, continuous use
should not persist beyond 3 to 5 days to reduce
the risk of developing rebound nasal congestion.21 If heavy bleeding persists despite the initial
dose (2-6 sprays or 30 minutes of soaked packs),
referral for assessment and further intervention
would be prudent.
Antifibrinolytics. Tranexamic acid (TXA), an
antifibrinolytic, has been the most extensively
studied of all of the products available for patient
self-treatment. However, high-quality, robust
data to support its routine use in patients with
epistaxis are still lacking.27 A randomized,
double-blind, parallel group trial of 68 patients
has found no difference in bleeding arrest at 30
minutes between TXA 10% gel and placebo (60%
TXA vs 76% placebo, p = 0.16).22 The high rate
of bleeding arrest observed with the placebo gel
may be partially explained in that fewer patients
randomized to placebo had severe epistaxis relative
to those receiving TXA. In contrast, an unblinded
randomized trial in patients with anterior
epistaxis (n = 216) observed a significantly
higher rate of bleeding cessation with placement
of TXA 100 mg/mL-soaked gauze compared to
those treated with epinephrine-soaked gauze
followed by anterior nasal packing (71% vs 31%,
p < 0.001).23 This also led to significantly more
TXA patients being discharged from the ER
within 2 hours compared to control (95% vs 6.4%,
p < 0.001). A recent open-label randomized trial
among 124 patients with anterior epistaxis taking
acetyl salicylic acid (ASA), clopidogrel, or both,
compared TXA-soaked gauze to anterior nasal
packing and demonstrated superiority of topical
TXA over nasal packing.24 Lastly, a randomized
placebo controlled trial (n = 89) used oral TXA
170



1 g 3 times daily as an adjunct to nasal packing
and/or cautery in patients with epistaxis.28 Those
with thromboembolic disease or who were taking
antithrombotic medications were excluded. Oral
TXA did not produce any benefit with respect to
rebleeding rates (47% TXA vs 57% placebo, p >
0.50) or hospital LOS (mean LOS: 5.42 days TXA
vs 5.02 days placebo, modal LOS: 3 days TXA vs
4 days placebo). The rate of adverse effects was
also not different between oral TXA and placebo.
Despite the inconclusive evidence for the efficacy
of TXA in epistaxis, topical TXA appears to pose
few to no risks to patients. A Cochrane review
of 29 randomized-controlled trials involving
2612 participants comparing topical TXA used
intra- or postoperatively for surgical indications
(and including only 1 trial of patients with
epistaxis) to control groups found no increase in
thromboembolic events, including myocardial
infarction, stroke, deep vein thrombosis and
pulmonary embolism.29 However, most of
the studies were underpowered to detect a
meaningful difference for this outcome. The same
inferences regarding benefit/risk profile cannot
be made for oral TXA, lending support to offer
only the topical TXA as a reasonable therapeutic
alternative. Topical TXA has also been used as a
preventative agent in patients prone to recurrent
epistaxis, particularly those taking anticoagulants.
A commercially available gel (Nozohaem™)
containing glycine and calcium-thought to
facilitate clot formation through activation of
endogenous coagulation processes-has been
marketed for the acute management of epistaxis.
A single-centre randomized trial of 40 patients
receiving this gel versus 60 patients getting anterior nasal packaging found the gel group superior to the packing group in terms of bleeding
cessation time, discharge time, pain score and
side effect profile.25
ER/hospital-based management strategies
Severe and life-threatening blood loss can occur
in select cases of epistaxis and should be managed in a hospital-based setting where rapid
assessment and monitoring of blood loss can
occur through serial measurements of complete blood cell counts and hemoglobin levels.
The stepwise treatment approach for severe
epistaxis may vary by institution but generally includes the use of mechanical strategies
(Table 3)3-5,7,10,30-37 and/or pharmacologic agents
(Table 4).18-20,22-24,28,38-50 Topical pharmacologic
C P J / R P C  *  M ay / J u n e  2 0 1 9  *  V O L  1 5 2 ,  N O  3
Canadian Pharmacists Journal - May/June 2019

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