Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

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 thromboembolic events. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or rebleeding rates in patients with acute upper gastrointestinal bleeding, and actually increased the risk of venous thromboembolic events. This study included a large randomized controlled trial of 12,009 patients, which provides strong evidence for the lack of benefit of TXA in this setting.

In terms of the mechanism of action, TXA works by inhibiting fibrinolysis, which can help stabilize blood clots that form at bleeding sites in the GI tract. 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 active bleeding may have a hypofibrinolytic state, which can further reduce the effectiveness of TXA.

The study published in 2019 in Gut 1 also found that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial. However, the more recent study published in 2022 1 provides stronger evidence for the lack of benefit of TXA in GI bleeding, and its potential harm in patients with cirrhosis and active variceal bleeding.

Some key points to consider when managing GI bleeding include:

• The use of vasoactive therapy, antibiotics, and endoscopic treatment as standard therapy for variceal bleeding
• The potential harm of administering large volumes of blood products, which can increase portal pressure and worsen outcomes
• The importance of a restrictive red blood cell transfusion strategy to minimize the risk of rebleeding and thrombotic events
• The need for individualized management of patients with cirrhosis and active bleeding, taking into account the underlying cause of bleeding and the patient's overall clinical condition.