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 effectiveness is not well established, particularly for lower GI bleeding. Some studies suggest that TXA may be beneficial in reducing mortality in upper GI bleeding, but the evidence is not strong enough to support its use as a standalone treatment 1. TXA works by inhibiting the breakdown of blood clots, and it is typically administered as 1 gram intravenously every 6-8 hours until bleeding stabilizes, or as a 1-1.5 gram oral dose three to four times daily. However, it should be used alongside primary interventions like endoscopic therapy, not as a standalone treatment. Caution should be exercised in patients with thromboembolic risk factors, as TXA may potentially increase clotting risk. Renal dose adjustment is necessary for patients with kidney impairment, typically reducing the dose by 25-50% for moderate to severe renal dysfunction. Side effects are generally mild and may include nausea, vomiting, and headache, with seizures being a rare but serious concern at high doses. In patients with hereditary hemorrhagic telangiectasia (HHT), TXA may be recommended for mild GI bleeding, but there is limited evidence of its effectiveness 1. Overall, the use of TXA in GI bleeding should be approached with caution and considered on a case-by-case basis, taking into account the underlying cause of the bleeding and the patient's individual risk factors. Key points to consider when using TXA for GI bleeding include:

• TXA should not be used as a standalone treatment, but rather alongside primary interventions like endoscopic therapy
• Caution should be exercised in patients with thromboembolic risk factors
• Renal dose adjustment is necessary for patients with kidney impairment
• Side effects are generally mild, but seizures can be a rare but serious concern at high doses
• The effectiveness of TXA in GI bleeding is not well established, particularly for lower GI 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.