Efficacy and safety of topical tranexamic acid in the management of anterior epistaxis: a systematic review and metaanalysis

Abstract

Background: The effectiveness of topical tranexamic acid (TXA) for spontaneous anterior epistaxis remains uncertain. We evaluated its efficacy and safety compared with placebo or standard care. Methodology: PubMed, Scopus, Web of Science, and Cochrane CENTRAL were searched through November 2025 for randomized controlled trials (RCTs) and comparative observational studies in adults with spontaneous anterior epistaxis. The primary outcome was bleeding cessation; secondary outcomes included overall hemostasis, rebleeding, resource utilization, and adverse events. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using the Hartung–Knapp–Sidik–Jonkman random-effects model. Results: Eleven studies (10 RCTs and 1 observational study; 1,811 patients) were included. TXA was associated with greater bleeding cessation within 10 minutes (RR 2.26, 95% CI 1.59–3.21), but this effect became non-significant after adjustment for publication bias, indicating uncertainty in rapid hemostatic efficacy. TXA improved overall hemostasis (RR 1.25, 95% CI 1.11–1.40), reduced rebleeding within 3 days (RR 0.39, 95% CI 0.28–0.55), and reduced ENT consultation (RR 0.54, 95% CI 0.38–0.75). No significant reductions were observed in nasal packing, hospital admission, or cauterization. Adverse events were comparable between groups. Conclusions: Topical TXA appears safe and may reduce short-term rebleeding and ENT consultation, but its benefit for rapid initial bleeding cessation is uncertain because of publication bias and small-study effects. It should be considered an adjunct rather than a definitive first-line hemostatic treatment.