From the Guidelines
Tranexamic acid (TXA) can be used to stop a GI bleed, but its effectiveness is still being studied, and it should be used with caution, particularly in patients with cirrhosis or variceal bleeding, as it may not be beneficial and could increase the risk of thrombotic events, as suggested by the most recent study 1. The use of TXA in GI bleeding is supported by some studies, which show that it can reduce mortality, particularly in high-risk patients or resource-limited settings where immediate endoscopy may not be available 1. However, other studies suggest that TXA may not be effective in certain types of GI bleeding, such as variceal bleeding, and may even increase the risk of thrombotic events 1. The recommended dosing of TXA is typically 1 gram administered intravenously over 10 minutes, followed by either additional doses or a continuous infusion of 1 gram over 8 hours, depending on clinical response. TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites in the GI tract. This antifibrinolytic mechanism prevents premature breakdown of clots, allowing them to remain intact long enough to effectively stop bleeding. TXA is most effective when administered early, ideally within 3 hours of bleeding onset, and should be considered alongside other standard treatments such as proton pump inhibitors, endoscopic interventions, and blood product transfusions as needed. While generally well-tolerated, clinicians should be aware of potential side effects including nausea, vomiting, and a theoretical risk of thrombotic events, though this risk appears low in most patients. In patients with cirrhosis or variceal bleeding, the use of TXA is not recommended, as it may not be beneficial and could increase the risk of thrombotic events 1. In these cases, other treatments such as vasoactive drugs, beta-blockers, and antimicrobial therapy may be more effective in managing GI bleeding 1. Overall, the use of TXA in GI bleeding should be individualized and based on the specific clinical scenario, taking into account the potential benefits and risks of treatment.
From the Research
Role of Tranexamic Acid in Managing Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been studied for its potential to manage gastrointestinal bleeding, with some studies suggesting it may be effective in reducing hemorrhage and mortality 2, 3.
- A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo in patients with upper gastrointestinal bleeding 2.
- Another study found that early administration of TXA may be worth recommending for treating upper gastrointestinal bleeding in the emergency department, although the effects of TXA on lower gastrointestinal bleeding warrant further clarification 2.
- However, other studies have reported conflicting results, with some finding no significant difference in mortality, rebleeding, or need for surgery between TXA and placebo 4, 5.
- The efficacy and safety of TXA in acute upper gastrointestinal bleeding have been evaluated in a meta-analysis, which found no significant difference in mortality, rebleeding, or need for surgery, but an increased risk of venous thromboembolic events with TXA 5.
Mechanism of Action and Potential Benefits
- TXA works by inhibiting the breakdown of fibrin clots, which can help to reduce bleeding in patients with gastrointestinal bleeding 6.
- The antifibrinolytic properties of TXA may aid in changing an urgent endoscopy to an elective procedure, with better outcomes for both physicians and patients 3.
- Low-dose IV/enteral TXA may be effective in reducing hemorrhage, although more evidence is required to demonstrate its safety 6.
Potential Risks and Limitations
- Extended-use high-dose IV TXA does not improve mortality or bleeding outcomes and increases adverse events, including deep venous thrombosis, pulmonary embolism, and seizure 6.
- The certainty of evidence for the efficacy and safety of TXA in gastrointestinal bleeding is generally low to very low, highlighting the need for further high-quality research 5.