What are the major risks and precautions associated with using tranexamic acid (TXA) in patients with gastrointestinal bleeding?

From the Guidelines

Tranexamic acid (TXA) should not be used in patients with cirrhosis and active variceal bleeding, as it may increase the risk of thrombotic events, particularly in those with comorbid liver disease or suspected variceal bleeding. The major risks associated with using TXA in patients with gastrointestinal bleeding include:

• Increased thrombotic events, such as venous thromboembolic events, which may be concentrated in patients with comorbid liver disease or suspected variceal bleeding 1
• Limited benefit in variceal bleeding due to the limited role of haemostasis in this condition and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis 1
• Potential for increased risk of arterial thromboembolic events, particularly when used in high doses or in patients with a history of thromboembolism 1
• Need for careful evaluation and monitoring in patients with renal impairment, as TXA is primarily eliminated through the kidneys 1 Key precautions when considering the use of TXA in GI bleeding include:
• Thorough screening for thromboembolic risk factors
• Monitoring for neurological symptoms, such as seizures, particularly in patients with a history of seizure disorders or renal impairment
• Checking renal function before administration and adjusting the dose accordingly
• Avoiding use in patients with subarachnoid hemorrhage due to increased risk of cerebral edema and infarction
• Using TXA as part of a comprehensive management approach that includes identifying and treating the underlying cause of bleeding, as recommended by the EASL clinical practice guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis 2.

From the Research

Major Risks of Using Tranexamic Acid (TXA) in Patients with Gastrointestinal Bleeding

• The use of tranexamic acid (TXA) in patients with gastrointestinal bleeding has been associated with several major risks, including:
  • Thrombotic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE) 3, 4, 5
  • Seizures, particularly with high doses of TXA 3, 6
  • Increased risk of mortality, particularly with extended-use high-dose IV TXA 3, 5
• The risk of thrombotic events with TXA use is a concern, particularly in patients with a history of thromboembolism or those at high risk of bleeding 4, 5
• The use of oral TXA has also been associated with an increased risk of venous thromboembolism in women 7

Precautions for Using TXA in Patients with Gastrointestinal Bleeding

• Patients with a history of thromboembolism or those at high risk of bleeding should be carefully evaluated before receiving TXA 4, 5
• The dose and duration of TXA use should be carefully considered to minimize the risk of adverse events 3, 6
• Patients receiving TXA should be closely monitored for signs of thrombotic events, seizures, and other adverse events 3, 6, 5
• The use of TXA in patients with gastrointestinal bleeding should be weighed against the potential benefits and risks, and alternative treatments should be considered when possible 3, 4, 5