What is the role of tranexamic acid (TXA) in managing Gastrointestinal (G.I.) bleeding?

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a G.I. bleed, particularly 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. The use of TXA in managing G.I. bleeding is not supported by recent evidence, including a large randomized placebo-controlled trial that included 12,009 patients with acute upper gastrointestinal bleeding, of which nearly 50% of cases were suspected variceal bleeding 1. This study found that TXA did not reduce mortality or re-bleeding rates in patients with suspected variceal bleeding and liver disease comorbidity. In fact, the study reported an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group.

Some key points to consider when managing G.I. bleeding include:

• The importance of prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment in patients with variceal bleeding
• The potential risks of correcting haemostatic abnormalities in patients with cirrhosis and active variceal bleeding, including the increased risk of thrombotic events
• The need for a restrictive red blood cell transfusion strategy to avoid increasing portal pressure and worsening outcomes
• The potential benefits of using recombinant factor VIIa in high-risk patients with active bleeding at endoscopy, although this should be weighed against the potential risks of thromboembolic events.

In terms of specific treatment approaches, the evidence suggests that:

• TXA should not be used as a first-line treatment for G.I. bleeding, particularly in patients with cirrhosis and active variceal bleeding
• Vasoactive therapy, such as terlipressin, somatostatin, or octreotide, should be initiated promptly in patients with variceal bleeding
• Endoscopic treatment, such as variceal ligation or sclerotherapy, should be performed as soon as possible in patients with variceal bleeding
• Blood product transfusion should be used judiciously, with a restrictive approach to avoid increasing portal pressure and worsening outcomes.

From the Research

Role of Tranexamic Acid in G.I. Bleeding

• Tranexamic acid (TXA) has been proposed as a treatment for gastrointestinal bleeding, with studies investigating its efficacy in reducing mortality, bleeding, and adverse events 2, 3, 4, 5, 6.
• The evidence suggests that TXA may have a beneficial effect on mortality, with a systematic review and meta-analysis finding a reduced risk of death with TXA compared to placebo or no intervention 4, 6.
• However, other studies have found no significant difference in mortality or bleeding outcomes with TXA compared to control groups 2, 5.
• Low-dose IV/enteral TXA may be effective in reducing rebleeding and the need for surgery, but more evidence is required to demonstrate its safety 2.
• High-dose IV TXA has been associated with an increased risk of adverse events, including deep venous thrombosis, pulmonary embolism, and seizure 2.

Efficacy of TXA in Upper G.I. Bleeding

• A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 3.
• Another study found that TXA may reduce all-cause mortality in upper gastrointestinal bleeding, but the evidence was limited by the quality of the included trials 4.
• A meta-analysis of randomized controlled trials found no significant difference in mortality, rebleeding, or need for surgery with TXA compared to control groups in upper gastrointestinal bleeding 5.

Safety of TXA in G.I. Bleeding

• The safety of TXA in gastrointestinal bleeding is a concern, with studies finding an increased risk of adverse events, including thromboembolic events, with high-dose IV TXA 2, 5.
• Low-dose IV/enteral TXA may be safer, but more evidence is required to demonstrate its safety 2.
• The risk of adverse events with TXA should be carefully considered when deciding whether to use it in patients with gastrointestinal bleeding 2, 5.