Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) may have a role in stopping a GI bleed, but its use should be confined to clinical trials or specific situations due to uncertain benefits and potential risks, as evidenced by the British Society of Gastroenterology guidelines 1. When considering the use of TXA for GI bleeding, it's crucial to weigh the potential benefits against the risks. The mechanism of action of TXA involves inhibiting plasminogen activation, which can help maintain clot stability in areas of bleeding. However, the evidence for its benefit in acute GI bleeding is not strong, with some studies suggesting a 40% risk reduction in mortality, but this benefit was not apparent in trials with low risk of bias 1. Key points to consider when evaluating the use of TXA for GI bleeding include:

• The uncertain extrapolation of historical trial data to modern day care, given the routine use of high-dose acid suppression and endoscopic therapy 1
• The lack of data on the effect of TXA on thromboembolic events in the context of GI bleeding, which is a significant concern given the potential for thrombotic complications
• The recommendation from the British Society of Gastroenterology to confine the use of TXA in acute LGIB to clinical trials, pending the results of the HALT-IT trial 1 In clinical practice, the decision to use TXA for GI bleeding should be made on a case-by-case basis, taking into account the individual patient's risk factors, the severity of the bleed, and the availability of other treatment options. The use of TXA should be carefully considered and monitored, with attention to the potential risks of thrombotic complications, particularly in patients with pre-existing cardiovascular disease or thrombotic tendencies 1.

From the Research

Efficacy of Tranexamic Acid in GI Bleeding

• The use of tranexamic acid (TXA) in gastrointestinal (GI) bleeding has been studied in several randomized controlled trials, with varying results 2, 3, 4, 5, 6.
• A systematic review and meta-analysis published in 2021 found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 2.
• Another study published in 2018 found that early administration of TXA reduced the need for urgent endoscopy in patients with acute GI bleeding 3.
• However, a 2022 systematic review and meta-analysis found that extended-use high-dose IV TXA did not improve mortality or bleeding outcomes and increased adverse events, while low-dose IV/enteral TXA may be effective in reducing hemorrhage 4.
• A 2020 meta-analysis found no significant difference in mortality, rebleeding, or need for surgery between TXA and placebo in acute upper GI bleeding, but an increased risk of venous thromboembolic events with TXA 5.
• A 2024 systematic review and meta-analysis found that TXA does not reduce mortality in patients with acute upper or lower GI bleeding and may confer an increased risk of seizures 6.

Safety and Adverse Events

• The safety profile of TXA in GI bleeding is a concern, with reports of increased risk of venous thromboembolic events 5 and seizures 4, 6.
• The 2022 systematic review and meta-analysis found that extended-use high-dose IV TXA increased the risk of deep venous thrombosis, pulmonary embolism, and seizure 4.
• The 2024 systematic review and meta-analysis found no increased risk of venous thromboembolic events, but an increased risk of seizures 6.

Clinical Implications

• The use of TXA in GI bleeding should be carefully considered, taking into account the potential benefits and risks 2, 3, 4, 5, 6.
• Further studies are needed to clarify the efficacy and safety of TXA in GI bleeding, particularly in different patient populations and with different dosing regimens 4, 6.