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 venous thromboembolic events, as shown in a large randomized placebo-controlled trial 1. The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in certain cases, such as upper GI bleeding 1. However, the most recent and highest quality study, a large randomized placebo-controlled trial, found 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 increased risk of venous thromboembolic events in the TXA group, particularly in patients with comorbid liver disease or suspected variceal bleeding. Some studies have evaluated the use of TXA in specific contexts, such as hereditary hemorrhagic telangiectasia (HHT) 1. In these cases, TXA may be recommended for patients with mild GI bleeding due to its low potential for harm, but the evidence of effectiveness is limited. In general, the use of TXA in GI bleeding should be approached with caution, taking into account the potential risks and benefits, as well as the underlying cause and location of the bleeding. The decision to use TXA should be made on a case-by-case basis, considering the individual patient's risk factors and the availability of other treatment options, such as endoscopic treatment, proton pump inhibitors, or other hemostatic measures 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 2022 found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 3.
- A meta-analysis published in 2020 found no significant difference in mortality, rebleeding, or need for surgery between TXA and placebo in patients with upper GI bleeding, but an increased risk of venous thromboembolic events with TXA 4.
- A more recent meta-analysis published in 2024 found that TXA with acid suppression significantly reduced the risk of rebleeding, units of blood transfused, and the need for salvage therapy in patients with upper GI bleeding 5.
- Another systematic review and meta-analysis published in 2020 found that TXA was superior to placebo for the reduction in mortality in patients with upper GI bleeding, with moderate-quality evidence 6.
Safety and Adverse Events
- The use of TXA in GI bleeding has been associated with an increased risk of venous thromboembolic events, deep venous thrombosis, pulmonary embolism, and seizure 3, 4.
- The safety and efficacy of TXA in lower GI bleeding warrant further clarification 2.