From the Guidelines
Tranexamic acid should not be used in patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect and may increase the risk of venous thromboembolic events. The use of tranexamic acid in gastrointestinal bleeding is a complex issue, and its effectiveness depends on the underlying cause of the bleeding. In the context of variceal bleeding, the evidence suggests that tranexamic acid is not effective in reducing bleeding or mortality 1. In fact, a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found that tranexamic acid had no beneficial effect in patients with suspected variceal bleeding and liver disease comorbidity 1. Furthermore, the trial reported an almost 2-fold increase in the incidence of venous thromboembolic events in the tranexamic acid group compared to the placebo group, particularly in patients with comorbid liver disease/suspected variceal bleeding 1.
Key Points to Consider
- The evidence is based on a high-quality study published in the Journal of Hepatology in 2022 1
- The study found no beneficial effect of tranexamic acid in patients with variceal bleeding
- The use of tranexamic acid may increase the risk of venous thromboembolic events, particularly in patients with comorbid liver disease/suspected variceal bleeding
- Standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment 1
Clinical Implications
- Tranexamic acid should not be used as a treatment for variceal bleeding in patients with cirrhosis
- The decision to correct haemostasis should be considered on a case-by-case basis, taking into account the individual patient's risk factors and underlying conditions 1
- A restrictive red blood cell transfusion strategy is beneficial in patients with variceal bleeding, as it may reduce the risk of re-bleeding and improve outcomes 1
From the Research
Tranexamic Acid and Gastrointestinal Bleeding
- Tranexamic acid has been proposed as a treatment for gastrointestinal bleeding, but its efficacy and safety are still debated 2, 3, 4, 5, 6
- 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 2
- However, another study found that extended-use high-dose IV tranexamic acid did not reduce mortality or bleeding outcomes and increased adverse events, such as deep venous thrombosis, pulmonary embolism, and seizure 3
- A large randomized controlled trial found that tranexamic acid did not reduce death from gastrointestinal bleeding and was not cost-effective in adults with acute gastrointestinal bleeding 4
- A comprehensive systematic review and meta-analysis found that tranexamic acid significantly reduced rebleeding rates and mortality in patients with acute gastrointestinal bleeding, particularly in upper gastrointestinal bleeding 5
- However, another meta-analysis found that tranexamic acid did not improve outcomes in acute upper gastrointestinal bleeding and may increase the risk of venous thromboembolic events 6
Efficacy of Tranexamic Acid
- Tranexamic acid has been shown to reduce rebleeding rates and mortality in patients with upper gastrointestinal bleeding 2, 5
- However, its efficacy in lower gastrointestinal bleeding is still unclear 2, 5
- The use of tranexamic acid may be associated with a significant reduction in mortality when administered through both oral and intravenous routes 5
Safety of Tranexamic Acid
- Tranexamic acid has been associated with an increased risk of thromboembolic events, such as deep venous thrombosis and pulmonary embolism 3, 4, 6
- The use of tranexamic acid may also be associated with an increased risk of seizure 3, 4
- However, the overall risk of adverse events with tranexamic acid is still unclear and requires further study 2, 3, 4, 5, 6