From the Guidelines
Tranexamic acid (TXA) should not be used to stop a GI bleed, especially in patients with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. The use of TXA in GI bleeding has been evaluated in several studies, including a large randomized placebo-controlled trial that showed no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. In fact, the study found an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group.
The mechanism of action of TXA involves inhibiting plasminogen activation, which helps maintain clot stability and reduce bleeding. However, in the context of variceal bleeding, the limited role of haemostasis and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis may explain why TXA is ineffective 1.
Some studies have suggested that TXA may be beneficial in upper GI bleeding, with modest reductions in mortality and rebleeding rates when used as an adjunct to standard treatments like proton pump inhibitors and endoscopic therapy 1. However, the most recent and highest quality study suggests that TXA should not be used in patients with cirrhosis and active variceal bleeding 1.
Key points to consider when managing GI bleeding include:
- Prompt endoscopic evaluation and treatment remain the cornerstone of GI bleed management
- TXA should not replace primary interventions like proton pump inhibitors and endoscopic therapy
- Caution is advised in patients with a history of thromboembolism due to the risk of thrombotic events
- The use of TXA in GI bleeding should be confined to clinical trials, pending the results of further studies 1.
From the Research
Efficacy of TXA in GI Bleed
- TXA has been shown to reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A double-blind randomized controlled trial found that early intravenous and/or intravenous plus topical administration of TXA reduces the need for urgent endoscopy for acute gastrointestinal bleeding 3.
- However, a systematic review and meta-analysis found that extended-use high-dose IV TXA does not improve mortality or bleeding outcomes and increases adverse events, while low-dose IV/enteral TXA may be effective in reducing hemorrhage 4.
Combination Therapy with Acid Suppression
- A meta-analysis of randomized controlled trials found that combining TXA with acid suppression significantly reduces the risk of rebleeding, units of blood transfused, and the need for salvage therapy in upper gastrointestinal bleeding patients 5.
- Another study found that TXA with acid suppression reduces the risk of rebleeding and improves outcomes in UGIB patients, but does not significantly reduce mortality or the need for blood transfusion 5.
Safety and Efficacy Concerns
- A systematic review and meta-analysis found that TXA does not improve outcomes in UGIB and may increase the risk of venous thromboembolic events 6.
- The certainty of evidence for the efficacy and safety of TXA in GI bleed is generally low to very low, highlighting the need for further research 4, 6.