From the Guidelines
Tranexamic acid (TXA) should not be used to stop a GI bleed, especially in patients with cirrhosis and variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in reducing mortality in upper GI bleeding 1. However, a more recent and higher-quality study 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.
The mechanism of action of TXA involves inhibiting fibrinolysis, which can help stabilize blood clots at bleeding sites. However, in the context of variceal bleeding, the role of haemostasis is limited, and the use of TXA may not be effective. Additionally, patients with cirrhosis and variceal bleeding often have a hypofibrinolytic state, which may further reduce the effectiveness of TXA.
Key points to consider when managing GI bleeding include:
- The use of standard treatments such as proton pump inhibitors, endoscopic interventions, and blood product replacement
- The importance of correcting haemostatic abnormalities on a case-by-case basis
- The potential risks and benefits of using TXA in GI bleeding, including the increased risk of thromboembolic events
- The need for a comprehensive management approach that takes into account the underlying cause of the bleeding, the patient's medical history, and the potential risks and benefits of different treatments.
In patients with cirrhosis and active bleeding related to portal hypertension, but not to varices, the use of TXA is not recommended. Instead, treatment should focus on correcting the underlying cause of the bleeding and managing the patient's portal hypertension. In patients with non-portal hypertensive causes of bleeding, the use of TXA may be considered on a case-by-case basis, but the potential risks and benefits should be carefully weighed.
From the Research
Effectiveness of TXA in Stopping 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 meta-analysis of randomized controlled trials found that TXA significantly reduced rebleeding rates overall, and this effect was more pronounced in studies with a lower risk of bias 3.
- Another study 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 gastrointestinal bleeding 4.
Safety and Adverse Events
- High-dose IV tranexamic acid has been associated with an increased risk of deep venous thrombosis, pulmonary embolism, and seizure 5.
- However, low-dose IV/enteral tranexamic acid may be effective in reducing hemorrhage with moderate certainty, and more evidence is required to demonstrate its safety 5.
- A meta-analysis found that TXA was linked to a significant increase in mortality in patients with lower GI bleeding, but overall reduction when only randomized controlled trials were included 3.
Comparison with Other Treatments
- TXA has been compared to placebo or no intervention, and antiulcer drugs, with results showing a beneficial effect on mortality, but high dropout rates in some trials mean that the results are not conclusive 6.
- A study found that TXA appeared to reduce the risk of surgery, but this result was no longer statistically significant in a random-effects meta-analysis 6.
Subgroup Analysis
- TXA has been shown to be effective in reducing rebleeding and mortality in patients with upper gastrointestinal bleeding, but its effects on lower gastrointestinal bleeding warrant further clarification 2, 3.
- The optimal dose and route of TXA administration for GI bleeding are still unclear and require further study 4, 3.