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

From the Guidelines

Tranexamic acid (TXA) should not be used as a first-line therapy to stop GI bleeding, as the evidence for its effectiveness is inconsistent and it may increase the risk of thrombotic complications. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or re-bleeding rates in patients with variceal bleeding, and actually increased the risk of venous thromboembolic events.

When considering the use of TXA in GI bleeding, it is essential to weigh the potential benefits against the risks. TXA works as an antifibrinolytic agent by inhibiting plasminogen activation and preventing the breakdown of blood clots, potentially stabilizing clots that form at bleeding sites in the GI tract. However, the evidence for its effectiveness in GI bleeding is limited, and other interventions such as proton pump inhibitors, endoscopic therapy, and correction of coagulopathy are generally preferred.

Some studies have suggested that TXA may be beneficial in specific cases of GI bleeding, such as in patients with hereditary hemorrhagic telangiectasia (HHT) 1. However, these findings are not generalizable to all patients with GI bleeding, and the use of TXA in these cases should be individualized and carefully considered.

In general, the use of TXA in GI bleeding should be approached with caution, particularly in patients with a history of thromboembolism or active cardiovascular disease. The potential risks of TXA, including thrombotic complications, must be carefully weighed against any potential benefits.

Key points to consider when evaluating the use of TXA in GI bleeding include:

• The evidence for TXA's effectiveness in GI bleeding is inconsistent and limited
• TXA may increase the risk of thrombotic complications, particularly in patients with a history of thromboembolism or active cardiovascular disease
• Other interventions, such as proton pump inhibitors, endoscopic therapy, and correction of coagulopathy, are generally preferred for the management of GI bleeding
• The use of TXA should be individualized and carefully considered, taking into account the specific clinical context and potential risks and benefits.

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.