NoPac study findings
Novel use of tranexamic acid to reduce the need for nasal packing in epistaxis (NoPac)
Nosebleeds (epistaxis) represent a common presentation to UK Emergency Departments (EDs) with over 60,000 presentations per year in the UK. Many of these patients will have factors which may predispose them to bleeding such as taking medication that thins the blood (anticoagulants) or having medical conditions such as telangiectasia, where blood vessels maybe enlarged and fragile. While nosebleeds often stop with first aid (pinching the soft part of the nose with thumb and index finger, use of an ice pack and adopting a position leaning forward) and simple treatments, these treatments don’t always work and some patients will require the insertion of a ‘nasal pack’ to control the bleeding. The nasal pack is inserted into the nostril by a doctor or nurse and either swells up or is inflated to squash the bleeding vessel. Although packing usually works and stops the bleeding it is recognised to be extremely uncomfortable and distressing for the patient. Most patients who have had their nose packed stay in hospital for two to three days.
Tranexamic acid (TXA) is a safe and cheap drug that reduces bleeding by making blood clots less likely to be broken down by the body’s natural pathways. TXA has been shown to reduce bleeding after accidents and in surgery, but its use inside the nose (‘topical’ TXA) to stop a severe nosebleed, has not been thoroughly tested.
The NoPAC study investigated whether topical TXA could help to control severe nosebleeds (those not controlled with simple measures), and reduce the need for patients to have a nasal pack inserted, compared to placebo (water). Whilst some studies such as this have been carried out before, this study was pragmatically designed to complement the current treatment of nosebleeds in UK EDs with a very robust trial design.
We recruited 496 people who had come to the ED with a severe nosebleed over 23 months from May 2017 till March 2019, making NoPac the biggest study of its kind to date. Half of these people (participants) received TXA and half received the placebo treatment. The TXA or placebo was soaked into a cotton wool roll and put into the bleeding nostril, then held in place with a nasal clip for 10 minutes. Neither the participants nor the clinicians (doctors or nurse practitioners) knew whether they had been given TXA or placebo.
We found that the number of participants requiring nasal packing in the ED was similar in each group (43.7% in the TXA group; 41.3% in the placebo group). We used statistical tests to see whether the difference was significant or simply due to chance. We concluded that there is no evidence that TXA reduces the need for nasal packing when compared to placebo. We also looked at whether the participants received any other treatment for the nosebleed, hospital admission and length of stay in hospital, and again found no differences between the groups. On the basis of these results, we will not be recommending topical TXA for treatment of severe nosebleeds in the ED.