From the Guidelines
Tranexamic acid (TXA) can be used to help stop gastrointestinal (GI) bleeding, particularly in patients with mild GI bleeding, as it has a low potential for harm, although the evidence of its effectiveness is limited. According to the study published in Blood in 2021 1, TXA is recommended for patients with mild GI bleeding. The study suggests that systemic therapies, including TXA, are the primary modality for managing GI bleeding, while procedural hemostatic treatments are recommended only for emergent or brisk bleeding.
The mechanism of action of TXA involves inhibiting the breakdown of blood clots, which helps control bleeding. However, the optimal dosage and administration route for TXA in GI bleeding are not well established. Some studies suggest that TXA can be administered intravenously or orally, but the evidence is not strong enough to support a specific dosing regimen.
It is essential to note that TXA should be used as part of a comprehensive approach to GI bleeding management, which may include endoscopic intervention, correction of coagulopathy, and treatment of the underlying cause. Additionally, caution is advised when using TXA in patients with a history of thrombosis, as it may increase the risk of thromboembolic events. The study published in Gut in 2019 1 suggests that the use of TXA in acute lower gastrointestinal bleeding should be confined to clinical trials, pending the results of further studies.
In terms of specific patient populations, TXA may be particularly useful in patients with coagulopathies or those on anticoagulant medications. However, more research is needed to fully understand the benefits and risks of TXA in these patient groups. Overall, while TXA can be a useful adjunct in the management of GI bleeding, its use should be individualized and based on a thorough assessment of the patient's underlying condition and potential risks.
From the Research
Efficacy of TXA in Stopping GI Bleeding
- TXA has been shown to reduce the need for urgent endoscopy in patients with acute gastrointestinal bleeding 2
- A meta-analysis of 23 studies demonstrated that TXA significantly reduced rebleeding rates overall (RR: 0.81,95% CI: 0.87-0.97) 3
- TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding (RR: 0.61,95% CI: 0.42-0.89) 4
- A systematic review and meta-analysis of individual patient data from 64,724 bleeding patients found that TXA reduced the odds of death by 16% (OR=0.84,95% CI: 0.78 to 0.91, p<0.0001) 5
- Another meta-analysis of 13 randomized controlled trials found that TXA significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo 6
Safety and Potential Side Effects
- No significant statistical differences were seen between treatment groups regarding mortality, re-bleeding, blood transfusion, and endoscopic and/or surgical intervention rates in one study 2
- TXA was linked to a significant increase in mortality in patients with lower GI bleeding (RR: 1.67,95% CI: 1.44-1.93) in another study 3
- There was no definitive evidence that TXA use is associated with thromboembolic events in several studies 3, 4, 5
- Adverse events were unclearly reported in some studies 4
Subgroup Analysis
- TXA use was associated with a mortality reduction when administered through both oral and intravenous routes (RR: 0.56,95% CI: 0.35-0.89) and in cases of upper GI bleeding (RR: 0.72,95% CI: 0.59-0.87) 3
- The need for surgical interventions was significantly reduced when considering only low risk of bias studies (RR: 0.85,95% CI: 0.75 to 0.97, I2=0%) 3
- TXA reduced the odds of death by 20% (0.80,0.73 to 0.88, p<0.0001) in patients treated within 3 hours of bleeding onset 5