What is the role of tranexamic acid (TXA) in managing gastrointestinal (GI) bleeds?

From the Guidelines

Tranexamic acid (TXA) should not be used 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 the management of gastrointestinal (GI) bleeds, the role of tranexamic acid (TXA) is limited and should be considered on a case-by-case basis.

• The use of TXA in acute lower GI bleeding is not recommended outside of clinical trials, pending the results of the HALT-IT trial 1.
• In patients with hereditary hemorrhagic telangiectasia (HHT), TXA may be considered for the management of mild GI bleeding, but its effectiveness is limited and it should not be used as a first-line treatment 1.
• The primary treatment for GI bleeding in patients with HHT is systemic antiangiogenic therapy, such as bevacizumab, which has been shown to improve hemoglobin levels and reduce the need for blood transfusions 1.
• In patients with cirrhosis, the management of GI bleeding should focus on correcting the underlying cause of the bleeding, such as variceal bleeding, and using treatments such as portal hypertension-lowering drugs and endoscopic therapy 1. Some key points to consider when managing GI bleeds include:
• The importance of early intervention and treatment to reduce morbidity and mortality
• The need for individualized treatment plans based on the underlying cause of the bleeding and the patient's specific needs
• The potential risks and benefits of using TXA and other treatments, such as thromboembolic events and the need for close monitoring.

From the Research

Role of Tranexamic Acid in Managing GI Bleeds

• Tranexamic acid (TXA) has been proposed as a treatment for gastrointestinal (GI) bleeding, with studies suggesting its effectiveness in reducing hemorrhage and mortality rates 2, 3, 4.
• 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 compared to placebo 2.
• Another study found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage and the need for surgery 5.
• A comprehensive systematic review and meta-analysis found that TXA significantly reduced rebleeding rates, particularly in upper GI bleeding, and reduced the need for surgical intervention when excluding high-risk bias studies 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 upper GI bleeding patients 4.

Efficacy of Tranexamic Acid in Upper GI Bleeding

• Studies have shown that TXA may reduce mortality and rebleeding rates in upper GI bleeding patients 2, 3, 4, 6.
• A Cochrane review found that TXA appeared to have a beneficial effect on mortality, but the results were limited by a high dropout rate in some trials 6.
• TXA has been shown to reduce the risk of surgery and the need for blood transfusions in upper GI bleeding patients, although the results are not always statistically significant 2, 4, 6.

Safety and Adverse Events

• Studies have found that TXA may increase the risk of thrombotic events, such as deep venous thrombosis and pulmonary embolism, particularly with extended-use high-dose IV TXA 5.
• However, other studies have found no significant difference in the risk of thromboembolic events between TXA and control interventions 3, 6.
• The safety and efficacy of TXA in GI bleeding patients require further study, particularly in terms of optimal dosing and administration routes 5, 3, 4, 6.