What is the role of tranexamic acid (TXA) in treating Gastrointestinal (GI) bleeding?

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed in patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect and may increase the risk of venous thromboembolic events 1. In general, the use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in reducing mortality, particularly in upper GI bleeds 1. However, the most recent and highest quality study, a large randomized placebo-controlled trial, found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. The recommended approach for managing GI bleeding involves standard treatments such as proton pump inhibitors, endoscopic interventions, and blood product replacement as needed. In patients with hereditary hemorrhagic telangiectasia (HHT), TXA may be considered for mild GI bleeding, but its effectiveness is limited and there is a lack of strong evidence to support its use 1. It is essential to weigh the potential benefits and risks of TXA in each individual case, considering factors such as the underlying cause of the GI bleed, the presence of thromboembolic risk factors, and the patient's overall clinical condition. Key points to consider when evaluating the use of TXA in GI bleeding include:

• The lack of strong evidence to support its use in variceal bleeding 1
• The potential increased risk of venous thromboembolic events 1
• The importance of individualizing treatment decisions based on the patient's specific clinical condition and underlying cause of the GI bleed.

From the Research

Role of Tranexamic Acid in Treating GI Bleeding

• Tranexamic acid (TXA) has been proposed as a treatment for gastrointestinal (GI) bleeding, with studies showing mixed results 2, 3, 4, 5, 6.
• A systematic review and meta-analysis of randomized controlled trials found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 2.
• Another study found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but increased adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 3.
• A meta-analysis of randomized controlled trials 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 GI bleeding 4.
• However, a systematic review and meta-analysis found that TXA did not improve outcomes in upper GI bleeding and may increase the risk of venous thromboembolic events 5.
• A comprehensive systematic review and meta-analysis found that TXA significantly reduced rebleeding rates, particularly in upper GI bleeding, and was associated with a mortality reduction when administered through both oral and intravenous routes 6.

Efficacy of TXA in GI Bleeding

• The efficacy of TXA in GI bleeding is still unclear, with studies showing mixed results 2, 3, 4, 5, 6.
• TXA may be effective in reducing hemorrhage in upper GI bleeding, but its effects on lower GI bleeding warrant further clarification 2.
• The optimal dose and route of TXA administration for GI bleeding are still unknown and require further study 4.
• TXA may be associated with an increased risk of thromboembolic events, particularly venous thromboembolic events 3, 5.

Safety of TXA in GI Bleeding

• The safety of TXA in GI bleeding is a concern, with studies showing an increased risk of adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 3.
• TXA may be associated with an increased risk of thromboembolic events, particularly venous thromboembolic events 3, 5.
• However, a comprehensive systematic review and meta-analysis found that there was no definitive evidence that TXA use is associated with thromboembolic events 6.
• The safety of TXA in GI bleeding requires further study and cautious interpretation, with individualized patient management recommended 6.