From the Guidelines
Tranexamic acid (TXA) should not be used as a primary treatment to stop a GI bleed, but it may be considered as an adjunctive therapy in specific cases. When considering the use of TXA in managing GI bleeding, it is essential to weigh the potential benefits against the risks. According to the British Society of Gastroenterology guidelines 1, there is some evidence to suggest that TXA may be beneficial in acute GI bleeding, with a 40% risk reduction in mortality in pooled analysis. However, this benefit was not apparent when the analysis was limited to trials at low risk of bias.
In the context of GI bleeding, TXA works by inhibiting fibrinolysis, which helps preserve blood clots that form at bleeding sites in the GI tract. This antifibrinolytic agent competitively blocks the lysine binding sites on plasminogen, preventing its conversion to plasmin and thus reducing clot breakdown. Some key points to consider when using TXA in GI bleeding include:
- TXA should not replace standard treatments like endoscopic intervention, proton pump inhibitors, or vasoactive drugs.
- TXA may be considered as a complementary therapy to reduce rebleeding rates and mortality, especially when given early in the course of bleeding.
- Clinicians should be cautious in patients with high thrombotic risk or severe renal impairment, as the drug is primarily excreted by the kidneys.
- The greatest benefit appears to be in patients with significant bleeding before definitive endoscopic therapy can be performed.
It is also worth noting that the guidelines recommend systemic therapies as the primary modality for managing GI bleeding, with procedural hemostatic treatments reserved for emergent or brisk bleeds 1. Tranexamic acid is recommended for patients with mild GI bleeding, but there is limited evidence of effectiveness. Ultimately, the decision to use TXA in GI bleeding should be made on a case-by-case basis, taking into account the individual patient's risk factors and the severity of the bleed.
From the Research
Role of Tranexamic Acid (TXA) in Managing Gastrointestinal (GI) Bleeding
- TXA is a synthetic antifibrinolytic drug that has been shown to be effective in treating serious hemorrhage, including bleeding from major trauma and post-operative interventions 2.
- The use of TXA in managing GI bleeding has been studied in several randomized controlled trials, with varying results 3, 4, 5, 6.
Efficacy of TXA in Reducing GI Bleeding
- A systematic review and meta-analysis of 13 randomized controlled trials found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 3.
- Another systematic review and meta-analysis of 23 studies found that TXA significantly reduced rebleeding rates and mortality in patients with upper GI bleeding, but was associated with increased mortality in patients with lower GI bleeding 5.
- A Cochrane review of 8 randomized controlled trials 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.
Safety of TXA in GI Bleeding
- The use of TXA has been associated with an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism 4.
- However, a systematic review and meta-analysis found no definitive evidence that TXA is associated with thromboembolic events 5.
- The safety of TXA in GI bleeding is still a topic of debate, and further research is needed to fully understand its risks and benefits 3, 4, 5, 6.
Clinical Implications
- The use of TXA in managing GI bleeding may be beneficial in reducing rebleeding rates and mortality, particularly in patients with upper GI bleeding 3, 5.
- However, the decision to use TXA should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 4, 5, 6.
- Further research is needed to fully understand the efficacy and safety of TXA in GI bleeding, and to determine its optimal dosing and administration regimen 3, 4, 5, 6.