Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis

Tranexamic acid (TXA) can be used in a wide variety of settings in the Emergency Department for its hemostatic effects. Topical applications of TXA are commonly utilized to control minor bleeding from epistaxis, lacerations, or dental extractions.^1–3 More in-depth reviews of topical TXA can be found on R.E.B.E.L EM⁴ and The Skeptics Guide to Emergency Medicine.⁵

In the United States, TXA is available as either a 100 mg/mL IV solution or 650 mg tablets. For topical applications, the IV formulation is most frequently used to soak dressings or gauze which are then applied to the affected area. Little published information exists regarding the use of topical TXA preparations made from tablets. Mouthwashes for anticoagulated patients undergoing minor oral surgeries have been utilized in dental practice.⁶ In a 2007 letter to the editor in Haemophila, Coetzee reports his success crushing TXA tablets and applying the powder to non-surgical skin wounds in two hemophiliac patients not responding to standard factor replacement therapies.⁷ To date, no literature is available describing the use of a TXA paste.

A paste made from TXA tablets offers similar hemostatic benefits of topical IV TXA administration and provides another option for drug delivery. Pastes may be easier to apply to, and/or remain on, certain anatomic locations.  Additionally, TXA tablets are less expensive than IV formulations. Vials of TXA cost approximately $100 compared to only $5 per 650 mg TXA tablet. At $100/dose compared to $15/dose, both patients and institutions benefit from utilizing TXA paste from a cost standpoint. Lastly, considering the current climate of drug shortages, of which IV TXA fell victim to in 2014, a topical TXA paste may be a reasonable alternative should the IV formulation become unavailable in the future.

Tranexamic acid 650 mg tablets

Trick of the Trade: Tranexamic Acid Topical Paste

Recipe

1. 3 TXA 650 mg tablets
2. About 2 mL sterile water for injection

Directions

1. Crush tablets with mortar and pestle and triturate into a fine powder
   • A pill crusher works almost as well if a mortar and pestle are not available
   • The paste can then be prepared in a plastic pill cup
2. Add sterile water in small aliquots (~0.5 mL) and mix until a thick paste is formed
3. Apply paste to desired site for 20-30 minutes and remove

Additional Considerations

• Use immediately upon compounding. Although oral mouthwashes containing tablets mixed in sterile water are reportedly stable for up to 5 days, stability data for the paste is not available.⁸
• Time to cessation of bleeding after topical TXA has been similar in our experience whether prepared from an IV or PO product.
• Epistaxis:
  • The paste may not be the best option for epistaxis as it may be difficult to remove all of the paste once applied in the nare(s).
  • Case reports exist for cessation of epistaxis in anticoagulated patients treated with topical IV TXA; however, it is unclear if a TXA paste will have similar results. ⁹
• Our institution created an electronic order entry for TXA paste to promote consistency and standardize the process of ordering as well as preparation downstairs in the main pharmacy.
• There is no published data regarding a topical paste recipe, therefore it is unclear if a smaller dose (e.g. 1-2 tablets) would be as effective as 3 tablets
• In countries where TXA is supplied as 500 mg tablets, it is reasonable to consider the use of four 500 mg tablets (2000 mg instead of 1950 mg). However, slightly more sterile water may be required to achieve the same consistency as with three 650 mg tablets.

Application to Clinical Practice

• For patients with minor bleeding not responding to direct pressure, consider topical TXA prior to the use of topical thrombin or more invasive therapies such as injectable lidocaine-epinephrine
• Locations of minor bleeding in which we have had success include:
  • Post-dental extractions
  • Scalp lacerations
  • Extremity lacerations

References

1. Patatanian E, Fugate S. Hemostatic mouthwashes in anticoagulated patients undergoing dental extraction. Ann Pharmacother. 2006;40(12):2205-2210. [PubMed]
2. Noble S, Chitnis J. Case report: use of topical tranexamic acid to stop localised bleeding. Emerg Med J. 2013;30(6):509-510. [PubMed]
3. Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389-1392. [PubMed]
4. Hughes D. Topical Tranexamic Acid for Epistaxis or Oral Bleeds – R.E.B.E.L. EM – Emergency Medicine Blog. R.E.B.E.L. EM – Emergency Medicine Blog. http://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/. Published July 14, 2014. Accessed October 29, 2016.
5. Milne K, Hanel E. SGEM#53: Sunday, Bloody Sunday (Epistaxis and Tranexamic Acid). The Skeptics Guide to Emergency Medicine. http://thesgem.com/2013/11/sgem53-sunday-bloody-sunday-epistaxis-and-tranexamic-acid/. Published November 18, 2013. Accessed October 29, 2016.
6. Ambados F. Letter to the editor. Preparing tranexamic acid 4.8% mouthwash. Australian Prescriber. 2003;26:75-77.
7. Coetzee M. The use of topical crushed tranexamic acid tablets to control bleeding after dental surgery and from skin ulcers in haemophilia. Haemophilia. 2007;13(4):443-444. [PubMed]
8. Lam M. Extemporaneous compounding of oral liquid dosage formulations and alternative drug delivery methods for anticancer drugs. Pharmacotherapy. 2011;31(2):164-192. [PubMed]
9. Utkewicz M, Brunetti L, Awad N. Epistaxis complicated by rivaroxaban managed with topical tranexamic acid. Am J Emerg Med. 2015;33(9):1329.e5-7. [PubMed]

Author information

Scott Dietrich, PharmD

ED Clinical Pharmacist
St. Joseph's Hospital
Tampa, FL

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