IV or Nebulized Tranexamic Acid for Hemoptysis

We read with great interest the article by Gopinath et al1Gopinath B. Mishra P.R. Aggarwal P. et al.Nebulized vs IV tranexamic acid for hemoptysis: a pilot randomized controlled trial.Chest. 2023; 163: 1176-1184Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar comparing nebulized vs IV tranexamic acid (TA) for hemoptysis. The authors concluded that the nebulized route would be more efficacious in administering TA for hemoptysis. However, the nebulized route is compared with a dose of TA that has never been studied in terms of efficacy. The efficacy of TA is attributable to its antifibrinolytic effect, which requires a plasma TA concentration of between 10 and 15 mg/L.2Picetti R. Shakur-Still H. Medcalf R.L. Standing J.F. Roberts I. What concentration of tranexamic acid is needed to inhibit fibrinolysis? A systematic review of pharmacodynamics studies.Blood Coagul Fibrinolysis. 2019; 30: 1-10Crossref PubMed Scopus (91) Google Scholar The dose of TA commonly used by the IV route is 1 g over 10 minutes, which enables the threshold of antifibrinolytic activity (>10 mg/L) to be reached as soon as the infusion of TA is complete, for a duration of 2.9 h.3Grassin-Delyle S. Semeraro M. Lamy E. et al.Pharmacokinetics of tranexamic acid after intravenous, intramuscular, and oral routes: a prospective, randomised, crossover trial in healthy volunteers.Br J Anaesth. 2022; 128: 465-472Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Thus, after 3 h, the antifibrinolytic activity of TA disappears until a new dose of TA is administered, which is why 1 g TA is generally administered over 8 h. The 500-mg IV dose has never been studied in terms of pharmacodynamics. It is therefore likely that this dose never reaches the antifibrinolytic plasma concentration of 10 mg/L, or only does so late and for a limited time. Furthermore, the authors do not specify the administration regimen (number and intervals of administration) of TA in their work, which makes it impossible to know whether IV TA had a repeated antifibrinolytic action over time. The results of this study are full of hope, particularly for resource-limited countries, because TA appears to be efficacious on all types of hemoptysis etiology, especially those present in resource-limited countries. Nevertheless, the authors nebulized TA using an Atom Sanilizer 303 machine, which is not the nebulization method traditionally used in resource-limited countries or in a prehospital setting where resources are scarce. The pneumatic aerosol mask is the usual choice, being much cheaper and easier to use. The widespread use of nebulized TA in the management of hemoptysis would therefore require further work using a pneumatic nebulizing mask. None declared. Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled TrialCHESTVol. 163Issue 5PreviewNebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis. Full-Text PDF ResponseCHESTVol. 164Issue 5PreviewWe appreciate the readers’ interest in our study comparing nebulized and IV tranexamic acid (TA) for hemoptysis. We would like to address the concerns regarding the dose of TA used, the pharmacodynamics of the IV dose, and the nebulization method employed in our study.1 Full-Text PDF