From the Guidelines
Tranexamic acid is not routinely recommended for lower gastrointestinal (GI) bleeding. While tranexamic acid has shown benefit in upper GI bleeding and other hemorrhagic conditions, evidence for its efficacy in lower GI bleeding is limited and inconclusive, as noted in a study published in 2021 1. If considering tranexamic acid in a lower GI bleed, the typical dosing would be 1 gram intravenously every 8 hours for up to 3 days, but this should only be done after consultation with a gastroenterologist or in the context of a clinical trial.
The primary management of lower GI bleeding should focus on:
- Resuscitation
- Correction of coagulopathy
- Endoscopic evaluation
- Targeted interventions based on the bleeding source
Tranexamic acid works by inhibiting fibrinolysis and stabilizing blood clots, but this mechanism may not be as effective for the diverse etiologies of lower GI bleeding compared to upper GI bleeding. Additionally, there are concerns about potential thromboembolic complications, especially in patients with risk factors. Current practice guidelines prioritize other interventions over tranexamic acid for lower GI bleeding management, as discussed in a review article from 2005 1 and updated guidelines from 2021 1.
Other studies, such as those published in 2005 1, provide further insight into the management of lower GI bleeding, but the most recent and highest quality evidence supports the use of other interventions over tranexamic acid. Therefore, tranexamic acid should not be used as a first-line treatment for lower GI bleeding, and its use should be carefully considered on a case-by-case basis.
From the Research
Tranexamic Acid for Lower GI Bleed
- The use of tranexamic acid in lower GI bleeding is still unclear, with limited and heterogeneous evidence 2.
- A systematic review and meta-analysis of randomized controlled trials found that tranexamic acid significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding, but its effects on lower gastrointestinal bleeding warrant further clarification 2.
- The European Society of Gastrointestinal Endoscopy (ESGE) recommends a restrictive red blood cell transfusion strategy in hemodynamically stable patients with acute lower gastrointestinal bleeding, but does not mention the use of tranexamic acid in its guidelines 3.
- A review of current management, controversies, and advances in lower GI bleeding highlights the need for a more reliable predictive tool for mortality, rebleeding, and requirement for surgery, and notes the potential benefits of combination therapy with angiography, endoscopy, and surgery, as well as the increasing use of haemostatic agents 4.
- A randomized placebo-controlled clinical trial found that tranexamic acid did not decrease blood loss or improve clinical outcomes in patients presenting with lower GI hemorrhage 5.
- A systematic review and meta-analysis of randomized controlled trials found that extended-use high-dose IV tranexamic acid did not reduce mortality or bleeding outcomes and increased adverse events, while low-dose IV/enteral tranexamic acid may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 6.
Key Findings
- Tranexamic acid may not be effective in reducing blood loss or improving clinical outcomes in patients with lower GI bleeding 5, 6.
- The use of tranexamic acid in lower GI bleeding requires further clarification and study 2, 6.
- Other management strategies, such as restrictive red blood cell transfusion and combination therapy with angiography, endoscopy, and surgery, may be effective in managing lower GI bleeding 3, 4.