Topical treatment with a blood-clot promoting drug to reduce bleeding

Hundreds of thousands of people worldwide suffer ill health caused by severe bleeding. Tranexamic acid is a drug that helps blood to clot and so it could help people who are bleeding. We already know that giving tranexamic acid intravenously (directly into the vein) reduces bleeding in accident victims and in patients having operations. But some doctors don't always give it this way because they are worried that it might have bad side effects in certain patients, such as causing blood clots where they are not wanted. An alternative way to give this drug is to mix it with sterile water and apply it directly to the bleeding surface (this is known as 'topical' application). Because less of the drug might be absorbed into the body when it is given this way, it could be less likely to have bad side effects.

This review looked at trials assessing the effects of topical tranexamic acid in patients who are bleeding. Twenty-nine trials were found; 28 involved patients bleeding during operations and one involved people with nosebleeds. When the results of these trials were gathered together they showed that when tranexamic acid was given topically, it reduced the amount of blood that patients lost and made it less likely that they had a blood transfusion.

The authors of this review concluded that topical tranexamic acid reduces bleeding in patients who are having an operation. But because there are no trials, we are not sure if it also reduces bleeding from other causes, such as childbirth or bleeding from stomach ulcers.

Authors' conclusions: 

There is reliable evidence that topical application of tranexamic acid reduces bleeding and blood transfusion in surgical patients, however the effect on the risk of thromboembolic events is uncertain. The effects of topical tranexamic acid in patients with bleeding from non-surgical causes has yet to be reliably assessed. Further high-quality trials are warranted to resolve these uncertainties before topical tranexamic acid can be recommended for routine use.

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Background: 

Intravenous tranexamic acid reduces bleeding in surgery, however, its effect on the risk of thromboembolic events is uncertain and an increased risk remains a theoretical concern. Because there is less systemic absorption following topical administration, the direct application of tranexamic acid to the bleeding surface has the potential to reduce bleeding with minimal systemic effects.

Objectives: 

To assess the effects of the topical administration of tranexamic acid in the control of bleeding.

Search strategy: 

We searched the Cochrane Injuries Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library; Ovid MEDLINE®, Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily and Ovid OLDMEDLINE®; Embase Classic + Embase (OvidSP); PubMed and ISI Web of Science (including Science Citation Index Expanded and Social Science Citation Index (SCI-EXPANDED & CPCI-S)). We also searched online trials registers to identify ongoing or unpublished trials. The search was run on the 31st May 2013.

Selection criteria: 

Randomised controlled trials comparing topical tranexamic acid with no topical tranexamic acid or placebo in bleeding patients.

Data collection and analysis: 

Two authors examined the titles and abstracts of citations from the electronic databases for eligibility. Two authors extracted the data and assessed the risk of bias for each trial. Outcome measures of interest were blood loss, mortality, thromboembolic events (myocardial infarction, stroke, deep vein thrombosis and pulmonary embolism) and receipt of a blood transfusion.

Main results: 

We included 29 trials involving 2612 participants. Twenty-eight trials involved patients undergoing surgery and one trial involved patients with epistaxis (nosebleed). Tranexamic acid (TXA) reduced blood loss by 29% (pooled ratio 0.71, 95% confidence interval (CI) 0.69 to 0.72; P < 0.0001). There was uncertainty regarding the effect on death (risk ratio (RR) 0.28, 95% CI 0.06 to 1.34; P = 0.11), myocardial infarction (RR 0.33, 95% CI 0.04 to 3.08; P = 0.33), stroke (RR 0.33, 95% CI 0.01 to 7.96; P = 0.49), deep vein thrombosis (RR 0.69, 95% CI 0.31 to 1.57; P = 0.38) and pulmonary embolism (RR 0.52, 95% CI 0.09 to 3.15; P = 0.48). TXA reduced the risk of receiving a blood transfusion by a relative 45% (RR 0.55, 95% CI 0.55 to 0.46; P < 0.0001). There was substantial statistical heterogeneity between trials for the blood loss and blood transfusion outcomes.

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