Tranexamic acid needs a make over

I was listening to the EMCRIT podcast today. As usual it was absolutely excellent, but on this occasion it was especially superb as Scott Weingart was joined by the wonderful Prof. Tim Coates from Leicester. Tim is an inspiring EM researcher and speaker who also happens to be largely responsible for one of the largest RCTs in Emergency Medicine history; CRASH-2. Now, this is no time to go over CRASH-2 again. The bottom line is that tranexamic acid is both cheap and fabulous for the treatment of major trauma patients.

We should give it, we should pretty much always give it and neither he nor I know why clinicians have not adopted it as widely as it should. Actually, that’s not entirely true, I have a theory and that is that it’s just not ‘cool’ as a treatment.

?

What do I mean by ‘cool’? Well it’s just a feeling really based on practicing medicine for many years. When new treatments come into practice we clinicians (and especially EPs with our love of shiny things), love them to be exciting, difficult, even perhaps dangerous. Think of the excitement around stroke thrombolysis in previous posts that seems to based on little evidence. That requires CT scans, expert opinions, senior input, expensive therapies and in our neck of the woods transfer to another facility. It’s difficult, it’s expensive, it’s dangerous….it’s ‘cool’.

Tranexemic acid is not cool. It’s dirt cheap and can be given by any doc in our department.

Just as aspirin used to get missed in the rush for thrombolysis for MI (in the days before PCI) we are now missing TXA in the rush for Whole Body CT, Shock packs and advanced transfusion management. I see history and wonder what we can do to help.

So, how do we make TXA cool? I sometimes think that if I lock it in the controlled drugs cupboard next to the tPA and the Ketamine then tell everyone that it’s potentially fatal and scare them half to death it might get used more often. Perhaps if someone raised the price to £500 a shot we might think of it more often? Obviously that’s ludicrous but we need to do something.

TXA needs a make over, any ideas?

…….but what else? Where do we go next with TXA? If it works in major trauma then what about other bleeding disorders? What will CRASH-3 which will look at TXA in head trauma tell us?  Then what might CRASH-x tell us in the future? Who knows but I was quite surprised to see that there is already evidence out there for it’s potential use in GI Bleeding in this BestBet from the Royal London Hospital. Not convincing but promising enough for consideration in the future?

I think so.

Simon Carley

9 Comments

  1. katherine potier

    Well I’ve been out of action for while and realise TXA is used alot now, and that seems to be more obvious since my return to work. I know what you mean about it not being cool-it needs to be in the same sentence as lets get iv access, take bloods, and get TXA… Does it have sexy packaging?!

    Reply
  2. drgdh

    Totally agree, both about the essentialness of the EMCRIT podcast (and a British guest too – think I have a new career aspiration) and about the under-appreciation of TXA. It’s easy to see how it gets forgotten in the excitement of major trauma massive transfusion…. cool drugs don’t get infused over 8 hours. And isn’t it a gynaecologists drug anyway?

    But we have no excuse for not using it. The benefits are small (about a 1.5% reduction in mortality, giving an NNT of 67) but real. Its cheap, and the evidence is good. If saving lives isn’t exciting enough for us then what is?

    Reply
  3. stemlyns

    Totally agree folks. It’s a no brainer really, like a lot of emergency medicine this is an area where it’s important to get the basics right….., and this really is the basics.

    No excuses, give the drug.

    Reply
  4. Pingback: Tranexamic acid - does the evidence stack up? - St Emlyns

  5. drlakshayemhay

    Is there a role of TXA in spontaneous Intracerebral bleeds? Thanks!

    Reply
    1. Simon Carley (Post author)

      Good question and one I don’t know the answer to. The CRASH 3 trial is looking at traumatic head bleeds at the moment and we may end up inferring information from that in the future.

      What do you think?

      https://ctu-web.lshtm.ac.uk/c3w/

      S

      Reply
      1. Lakshay

        I totally agree – we ll have atleast some connection between the traumatic and non traumatic head bleeds. So may be that data could be extrapolated !

        Thanks!
        Lakshay

      2. Michael Stewart

        TICH-2 may also help to shoe any benefit in spontaneous bleeds http://www.controlled-trials.com/ISRCTN93732214/

        Michael

  6. Pingback: JC: Does earlier TXA save lives? St.Emlyn's - St.Emlyn's

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