From the Guidelines
Tranexamic acid (TXA) should not be used as a primary treatment to stop a gastrointestinal (G) bleed outside of clinical trials, as its benefit in acute GI bleeding is uncertain and requires further investigation, as suggested by the British Society of Gastroenterology guidelines 1.
Role of TXA in Gastrointestinal Bleeding
The use of TXA in managing gastrointestinal bleeding is a topic of ongoing research and debate. While TXA has been shown to improve mortality from trauma when given intravenously in the acute setting 1, its role in acute GI bleeding is less clear. Several trials of TXA in upper GI bleeding (UGIB) have been carried out, which on pooled analysis showed a 40% risk reduction in mortality 1. However, this treatment benefit for mortality was no longer apparent when the analysis was limited to trials at low risk of bias.
Current Recommendations
Given the uncertainty surrounding the use of TXA in acute GI bleeding, the British Society of Gastroenterology suggests that its use be confined to clinical trials, pending the results of the HALT-IT trial 1. This approach prioritizes the need for high-quality evidence to guide clinical practice and ensures that patients receive the most effective and safe treatment for their condition.
Comprehensive Approach to GI Bleeding Management
In the management of GI bleeding, a comprehensive approach is essential, incorporating endoscopic interventions, proton pump inhibitors, and blood product transfusions as needed. While TXA may be considered as part of this approach, its use should not delay definitive interventions like endoscopy for diagnosis and treatment of the bleeding source. Clinicians should exercise caution when considering TXA, particularly in patients with high thromboembolic risk, severe renal impairment, or history of seizures.
Key Considerations
- TXA's benefit in acute GI bleeding is uncertain and requires further investigation.
- The British Society of Gastroenterology recommends that TXA's use be confined to clinical trials.
- A comprehensive approach to GI bleeding management is essential, incorporating multiple treatment modalities as needed.
- Clinicians should exercise caution when considering TXA, particularly in high-risk patients.
From the Research
Role of Tranexamic Acid in Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been studied for its potential to manage gastrointestinal bleeding, with evidence suggesting it can reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo in patients with upper gastrointestinal bleeding 2.
- Another study found that early administration of TXA may be beneficial in treating upper gastrointestinal bleeding in the emergency department, although the effects of TXA on lower gastrointestinal bleeding require further clarification 2.
Efficacy of Tranexamic Acid in Reducing Bleeding
- A double-blind randomized controlled trial found that intravenous TXA reduced the need for urgent endoscopy in patients with acute gastrointestinal bleeding, with a significant reduction in the time to endoscopy 3.
- A systematic review and meta-analysis found that low-dose IV/enteral TXA reduced the risk of rebleeding and the need for surgery, although the evidence was of moderate certainty 4.
- A high-dose 24-hour TXA infusion did not reduce mortality or bleeding outcomes, but increased adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 4, 5.
Combination Therapy with Acid Suppression
- A meta-analysis of randomized controlled trials found that combining TXA with acid suppression significantly reduced the risk of rebleeding, units of blood transfused, and the need for salvage therapy in patients with upper gastrointestinal bleeding 6.
- The study suggested that combining TXA with acid suppression may be a beneficial first-line therapy for upper gastrointestinal bleeding patients, although further trials are needed to determine the optimal dose and route of TXA administration 6.