Inroduction
Hemoptysis is a common and potentially life-threatening condition that requires prompt diagnosis and management. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been shown to reduce bleeding in various clinical settings, such as trauma, surgery, and menorrhagia. However, the efficacy and safety of inhaled TXA for hemoptysis are still unclear. This review aims to summarize the current evidence on the efficacy and safety of TXA for hemoptysis.
How would you administer tranexamic acid for treating patients with hemoptysis?
500 mg IV, three times daily for up to 5 days.
1 g IV loading dose, then 1 g infusion over 8 hours.
Nebulized: 500 mg/5 mL, three times daily for up to 5 day
I do not use it!
Evidence for the Use of Tranexamic Acid in Hemoptysis
In a small study, 47 patients with nonmassive hemoptysis were randomized to receive either TA inhalations (500 mg/5 mL three times daily for up to 5 days) or normal saline. Results showed that TA significantly reduced expectorated blood volume from day 2, with 96% of patients experiencing resolution of hemoptysis within 5 days compared to 50% of the placebo group. Additionally, the TA group had a shorter hospital stay and required fewer invasive procedures to control bleeding. No side effects were observed in either group, and a reduced recurrence rate was noted at the 1-year follow-up. The study concluded that inhaled TA can be used safely and effectively to control bleeding in patients with nonmassive hemoptysis [1].
Another single-blinded, prospective study examined the efficacy and safety of tranexamic acid (TA) in controlling hemoptysis in 66 patients with sub-massive hemoptysis. Patients were randomized into treatment and placebo control groups, with the treatment group receiving intravenous TA (a loading dose of 1 g, followed by 1 g over 8 h infusion) and the control group receiving normal saline. Results showed that on day 2, the treatment group had lower frequency, quantity, and visual analogue scale (VAS) scores of hemoptysis compared to the control group, and fewer patients needed intervention. Additionally, the treatment group had a lower mean blood transfusion and shorter hospital stays. The treatment group's outcomes were better, with a statistically significant difference in VAS scores. No adverse events were noted during the study. The authors concluded that TA reduces the severity of hemoptysis and can be used as a bridging therapy before definitive intervention is undertaken [2].
A systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of tranexamic acid (TXA) in reducing hemoptysis volume and duration was published in 2020. The pooled results of 4 RCTs showed no significant differences in bleeding duration or hemoptysis resolution between the TXA and control groups. However, TXA use did reduce bleeding volume, further intervention risk, and length of hospital stay. The results may have low statistical power due to the limited sample size. The authors recommended additional large-scale RCTs to confirm the effectiveness and safety of TXA use [3].
Another recent meta-analysis aimed to evaluate the effect of tranexamic acid (TXA) on mortality in patients with hemoptysis. Five studies with a total of 20,047 patients were analyzed. When compared with the control group, TXA administration was associated with reduced short-term mortality, shorter bleeding time, shorter length of hospital stay, and a lower need for intervention in patients with hemoptysis. The use of TXA did not cause increased major or minor adverse effects [4].
More recently, a study aimed to compare the effectiveness of nebulized and intravenous (IV) tranexamic acid (TA) in reducing hemoptysis in patients presenting to the emergency department (ED). The study was an open-label, cluster-randomized, single-center pilot trial that included adult patients with active hemoptysis and excluded those who were hemodynamically unstable or required immediate intervention or mechanical ventilation. Results showed that hemoptysis cessation was significantly higher in the nebulization arm (40 patients) compared to the IV arm (28 patients) at 30 minutes. Hemoptysis amount was also significantly reduced in the nebulization arm at all observation time periods. Fewer patients in the nebulization arm required bronchial artery embolization and had higher ED discharge rates. The authors concluded that nebulized TA may be more effective than IV TA in reducing hemoptysis and the need for ED interventional procedures, but larger studies are needed to further explore this potential [5].
CONCLUSION
In conclusion, tranexamic acid (TXA) shows promise in the management of hemoptysis, a potentially life-threatening condition. Various studies and meta-analyses have demonstrated the effectiveness and safety of TXA, with both inhaled and intravenous routes of administration, in reducing hemoptysis, shortening hospital stays, and lowering the need for further intervention. In particular, nebulized TA may be more effective than IV TA in reducing hemoptysis and the need for ED interventional procedures. However, larger scale randomized controlled trials are needed to confirm the effectiveness and safety of TXA use in hemoptysis patients. Additionally, further research is necessary to determine the optimal route of administration and dosing regimen for TXA in this clinical setting.
REFERENCES:
1. Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Dec;154(6):1379-1384. doi: 10.1016/j.chest.2018.09.026. Epub 2018 Oct 12. PMID: 30321510.
2. Bellam BL, Dhibar DP, Suri V, Sharma N, Varma SC, Malhotra S, Bhalla A. Efficacy of tranexamic acid in haemoptysis: A randomized, controlled pilot study. Pulm Pharmacol Ther. 2016 Oct;40:80-3. doi: 10.1016/j.pupt.2016.07.006. Epub 2016 Jul 25. PMID: 27470681.
3. Tsai YS, Hsu LW, Wu MS, Chen KH, Kang YN. Effects of Tranexamic Acid on Hemoptysis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig. 2020 Sep;40(9):789-797. doi: 10.1007/s40261-020-00946-y. PMID: 32661913.
4. Chen LF, Wang TC, Lin TY, Pao PJ, Chu KC, Yang CH, Chang JH, Hsu CW, Bai CH, Hsu YP. Does tranexamic acid reduce risk of mortality on patients with hemoptysis?: A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2021 May 21;100(20):e25898. doi: 10.1097/MD.0000000000025898. PMID: 34011056; PMCID: PMC8137080.
5. Gopinath B, Mishra PR, Aggarwal P, Nayaka R, Naik SR, Kappagantu V, Shrimal P, Ramaswami A, Bhoi S, Jamshed N, Sinha TP, Ekka M, Kumar A. Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial. Chest. 2022 Nov 19:S0012-3692(22)04171-X. doi: 10.1016/j.chest.2022.11.021. Epub ahead of print. PMID: 36410494.
I am a big fan when its needed,  it’s a tool in my back pocket before the study came out but unfortunately it’s not available readily in the bronchoscopy suite
I got a pt in my clinic who comes with significant hemoptysis every time she get copd exacerbation and needs to be in hospital with an unrevealing bronch.
Her extensive cancer work up is negative.
Wish inhaled TXA to be available as out pt some time in the near future.