Can Tranexamic Acid (TXA) stop a Gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) should not be used as a first-line treatment to stop a GI bleed, as the most recent and highest quality evidence suggests it does not provide a significant benefit in reducing mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, including those with variceal bleeding. According to the study published in the Journal of Hepatology in 2022 1, a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of tranexamic acid in reducing death due to bleeding within the first 5 days. Furthermore, the study reported an almost 2-fold increase in the incidence of venous thromboembolic events in the tranexamic acid group compared to the placebo group.

The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in certain situations, such as in patients with trauma or postpartum hemorrhage. However, in the context of GI bleeding, the evidence is less robust, and the risks of thromboembolic events may outweigh any potential benefits. The British Society of Gastroenterology guidelines published in 2019 1 suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial.

In clinical practice, the management of GI bleeding should focus on standard endoscopic interventions, correction of coagulopathy, and acid suppression, with TXA reserved for specific cases or as part of a comprehensive treatment approach when other methods are insufficient or unavailable. The dosing and duration of TXA treatment may vary depending on the specific clinical scenario, but the typical dosing is 1g given intravenously every 6-8 hours for 24-48 hours.

Key points to consider when managing GI bleeding include:

• Standard endoscopic interventions, such as endoscopic therapy and acid suppression, remain the cornerstones of GI bleed management
• Correction of coagulopathy, such as transfusion of blood products, may be necessary in certain situations
• TXA should not be used as a first-line treatment to stop a GI bleed, due to the lack of evidence supporting its effectiveness and the potential risks of thromboembolic events
• The use of TXA in GI bleeding should be individualized and based on the specific clinical scenario, with careful consideration of the potential benefits and risks.

From the Research

Efficacy of TXA in GI Bleed

• The efficacy of tranexamic acid (TXA) in stopping a gastrointestinal (GI) bleed has been investigated in several studies 2, 3, 4, 5, 6.
• A systematic review with meta-analysis published in 2021 found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo in patients with upper GI bleeding 2.
• Another systematic review and meta-analysis published in 2022 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 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 found an increased risk of venous thromboembolic events with TXA 4.
• An earlier systematic review published in 2014 found that TXA appeared to have a beneficial effect on mortality, but the results were limited by a high dropout rate in some trials 5.
• A systematic review with meta-analysis published in 2020 found moderate-quality evidence that TXA is superior to placebo for reducing mortality in patients with upper GI bleeding, but found no statistically significant differences between TXA and placebo for other outcomes such as re-bleeding or need for surgical interventions 6.

Safety and Adverse Events

• The safety and adverse event profile of TXA in patients with GI bleed has been investigated in several studies 2, 3, 4, 5, 6.
• Some studies have found an increased risk of venous thromboembolic events, deep venous thrombosis, pulmonary embolism, and seizure with TXA 3, 4.
• Other studies have found no significant difference in adverse events between TXA and placebo 2, 5, 6.

Clinical Implications

• The use of TXA in patients with GI bleed may be beneficial in reducing mortality and hemorrhage, but the evidence is not consistent across all studies 2, 3, 4, 5, 6.
• The decision to use TXA in patients with GI bleed should be made on a case-by-case basis, taking into account the individual patient's risk factors and clinical presentation 2, 3, 4, 5, 6.