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 role of TXA in treating GI bleeding is still being studied, and its use is not universally recommended. For acute upper GI bleeding, some studies suggest that TXA may be beneficial in reducing mortality, with a 40% risk reduction in mortality reported in pooled analysis of several trials 1. However, this benefit was not seen in trials with low risk of bias, and the evidence is less robust for lower GI bleeding. TXA works by inhibiting the breakdown of blood clots, preventing plasmin from degrading fibrin clots that form at bleeding sites, and promoting hemostasis. Some guidelines recommend using TXA for patients with mild GI bleeding, but the evidence for its effectiveness is limited 1. In patients with cirrhosis and active bleeding related to portal hypertension, the use of TXA is not recommended, and correction of coagulopathy should be considered on a case-by-case basis 1. Key points to consider when using TXA for GI bleeding include:

• Starting TXA as soon as possible after bleeding is identified, ideally within the first few hours
• Using TXA alongside other standard treatments like endoscopic therapy, acid suppression, and blood product replacement as needed
• Exercising caution in patients with high thrombotic risk, and making dose adjustments necessary in renal impairment
• Being aware of the potential for TXA to increase the risk of venous thromboembolic events, particularly in patients with cirrhosis and active variceal bleeding.

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.