Canadian Pharmacists Journal - May/June 2019 - 172

PRACTiCeTOOL
Table 4

Pharmacologic agents for treatment of epistaxis in the acute care setting

agent

Mechanism of action

Technique for use

Gelatin-thrombin
matrix38-43,47 (e.g., FloSeal™)

Supplied as 2 separate components:
human thrombin and gelatin matrix.
When mixed and applied to active
bleed, thrombin in the gel converts
fibrinogen in blood into insoluble
fibrin. This initiates the development
of a hemostatic plug, forming a clot at
the site of bleeding.

For topical use only. May be applied following
application of topical vasoconstrictors.
Mix thrombin solution and gelatin matrix as per
manufacturer instructions.
With or without endoscopic guidance, using the
supplied syringe and applicator, the matrix
is applied directly to the source of bleeding.
Reapplication may be necessary if bleeding
persists.

Fibrin glue44,48,49

Supplied as separate components of
sealer protein component (containing
fibrinogen) and thrombin-calcium
component. When mixed, thrombin
activates the fibrinogen into fibrin.
Direct application of fibrin allows for
placement of an exogenous clot to
the site of bleeding.

May be applied following application of topical
vasoconstrictors.
Separate components are loaded into 2 syringes
and placed into a 2-channel syringe device, as
per manufacturer instructions. As the syringes
are depressed, the fibrin precipitates in the
mixing chamber and is then deposited directly
onto the site of bleeding.

Topical vasoconstrictors
(e.g., oxymetazoline,
xylometazoline18-20)

Alpha-adrenergic agonists stimulate
vasoconstriction of the blood vessels
in the nasal mucosa to reduce rate
and extent of bleeding.

Various doses and techniques have been studied.
Some administer in a nasal spray (dose range 2-6
sprays per nostril), whereas others place a cotton
pledget soaked with a solution of decongestant
drug in the nasal cavity for 30 minutes.

Desmopressin45

A synthetic analogue of antidiuretic
hormone. Increases plasma factor VIII,
thereby increasing overall coagulation
activity. Thought to have a direct and
local effect on blood vessel walls that
enhances platelet adhesion.

In a cohort of patients with postoperative
epistaxis, a single dose of desmopressin 0.3 μg/
kg intravenously (IV) was used.

Systemic antibiotics46,50

Purported use is adjunct in nature.
May be used in prolonged retention
of nasal packing for prevention of
toxic shock syndrome secondary to
Staphylococcus aureus infection and/
or sinusitis or bacteremia secondary
to nasal mucosa manipulation.

Agents used:
- Amoxicillin/clavulanate (dose not specified)
- Cefazolin 1 g IV q8h
May be used with or without concurrent use of
antibiotic-impregnated nasal packing.

Tranexamic acid22-24,28

Competitively inhibits the conversion
of plasminogen to plasmin, thereby
producing an antifibrinolytic effect.

Various routes of administration have been
studied:
- Cotton pledget soaked in 100 mg/mL
tranexamic acid injectable solution placed in
nasal cavity
- 10% tranexamic acid gel, filling the entire
affected nostril
- Tranexamic acid 1 g PO TID × 10 days

Concomitant antithrombotic therapy
Patients with epistaxis on anticoagulant or antiplatelet therapies are generally treated no differently from those not taking such agents, in
that self-management strategies should be tried
172

initially and if bleeding persists, then patients
should be referred for further assessment. One
may have a lower threshold for referral to acute
care in patients taking antithrombotics due to
the increased likelihood that they may require
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Canadian Pharmacists Journal - May/June 2019

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