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 found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. In fact, the trial found an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group. The European Association for the Study of the Liver (EASL) clinical practice guidelines also recommend against the use of TXA in patients with cirrhosis and active variceal bleeding, citing a lack of evidence for its effectiveness and potential risks 1.

The management of G.I. bleeding, particularly in patients with cirrhosis, should focus on standard therapies such as prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment. Correction of haemostatic abnormalities is not indicated in patients with cirrhosis and active variceal bleeding, unless there is a specific indication, such as severe haemostatic abnormalities 1. The use of recombinant factor VIIa has been evaluated in some studies, but its effectiveness is still uncertain and it may be associated with an increased risk of arterial thromboembolic events 1.

In summary, the current evidence does not support the use of TXA to stop a G.I. bleed, and its use should be avoided in patients with cirrhosis and active variceal bleeding due to the potential risks and lack of beneficial effect. Instead, standard therapies should be used to manage G.I. bleeding, and correction of haemostatic abnormalities should be considered on a case-by-case basis. Key points to consider include:

• TXA is not effective in stopping G.I. bleeding in patients with cirrhosis and active variceal bleeding
• TXA may increase the risk of venous thromboembolic events
• Standard therapies, such as vasoactive therapy, antibiotics, and endoscopic treatment, should be used to manage G.I. bleeding
• Correction of haemostatic abnormalities should be considered on a case-by-case basis, unless there is a specific indication.

From the Research

Role of Tranexamic Acid in G.I. Bleeding

• Tranexamic acid (TXA) has been proposed as a treatment for gastrointestinal (G.I.) bleeding, with studies yielding mixed results 2, 3, 4, 5, 6.
• A systematic review and meta-analysis of randomized controlled trials found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but increased adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 2.
• Another study found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper G.I. bleeding 3.
• A meta-analysis of randomized controlled trials found that TXA did not improve outcomes in upper G.I. bleeding and may increase the risk of venous thromboembolic events 4.
• A Cochrane review found that TXA appears to have a beneficial effect on mortality, but the results were limited by a high dropout rate in some trials 5.
• A systematic review and individual patient data meta-analysis of 64,724 bleeding patients found that TXA reduced the odds of death by 16% and did not increase the odds of vascular occlusive events 6.

Efficacy of TXA in G.I. Bleeding

• The efficacy of TXA in G.I. bleeding is still unclear, with different studies yielding conflicting results 2, 3, 4, 5, 6.
• Some studies suggest that TXA may be effective in reducing bleeding and mortality in patients with upper G.I. bleeding 3, 6.
• However, other studies found that TXA did not improve outcomes in G.I. bleeding and may increase the risk of adverse events 2, 4.

Safety of TXA in G.I. Bleeding

• The safety of TXA in G.I. bleeding is a concern, with some studies finding an increased risk of adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 2, 4.
• However, other studies found that TXA did not increase the odds of vascular occlusive events 6.
• The risk of adverse events associated with TXA use in G.I. bleeding needs to be carefully weighed against its potential benefits 2, 3, 4, 5, 6.