From the Guidelines
Tranexamic acid (TXA) should not be used as a first-line therapy for gastrointestinal (GI) bleeding, as current evidence does not strongly support its routine use in GI bleeding management. TXA is an antifibrinolytic agent that works by inhibiting the breakdown of blood clots, which theoretically could help control bleeding. However, large clinical trials, such as the one mentioned in 1, have shown modest or no benefit in mortality reduction or prevention of rebleeding compared to standard treatments.
The primary management of GI bleeding should focus on:
- Hemodynamic stabilization
- Proton pump inhibitor therapy (such as pantoprazole 80mg IV bolus followed by 8mg/hr infusion for upper GI bleeding)
- Prompt endoscopic evaluation and intervention
TXA may be considered as an adjunctive therapy in specific cases where other treatments have failed or are unavailable, but it should not delay definitive endoscopic or surgical management. The medication carries risks of thromboembolic complications, particularly in patients with predisposing factors for clotting disorders, which further limits its widespread application in GI bleeding, as noted in 1.
In fact, the most recent and highest quality study, 1, recommends against the use of tranexamic acid in patients with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and increased risk of venous thromboembolic events. This recommendation can be extrapolated to the general management of GI bleeding, where the risks and benefits of TXA should be carefully considered on a case-by-case basis.
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 thromboembolic events 3, 5.
- TXA may be associated with an increased risk of deep venous thrombosis, pulmonary embolism, and seizure 3.
- 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, particularly in patients with a high risk of thromboembolic events 6.