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 even increase the risk of venous thromboembolic events. The use of TXA in managing G.I. bleeding has been evaluated in several studies, 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 had no beneficial effect on death due to bleeding within the first 5 days, and actually increased the incidence of venous thromboembolic events, particularly in patients with comorbid liver disease or suspected variceal bleeding.

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. In contrast, other studies have suggested that TXA may be beneficial in certain contexts, such as in patients with upper GI bleeding who are at high risk of re-bleeding 1. However, these findings are not applicable to patients with cirrhosis and variceal bleeding, and the most recent and highest-quality evidence suggests that TXA should not be used in this population.

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, including the risk of thromboembolic events
• The need for individualized management approaches, taking into account the underlying cause of the bleeding and the patient's overall clinical condition
• The lack of evidence to support the use of TXA in patients with cirrhosis and variceal bleeding, and the potential risks associated with its use.

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 individual patient data from 64,724 bleeding patients found that TXA reduced the odds of death by 16% and did not increase the odds of vascular occlusive events 5.
• A comprehensive systematic review and meta-analysis found that TXA significantly reduced rebleeding rates and mortality in patients with upper G.I. bleeding, but was associated with a significant increase in mortality in patients with lower G.I. bleeding 6.

Efficacy and Safety of TXA in G.I. Bleeding

• The efficacy and safety of TXA in G.I. bleeding are still debated, with some studies suggesting a potential benefit in reducing bleeding and mortality, while others raise concerns about adverse events such as thromboembolic events 4, 6.
• The results of the HALT-IT trial, which found no evidence that TXA reduces death, have been questioned by some studies that suggest a reduction in mortality when TXA is administered early and in certain sub-groups of patients 5, 6.
• The use of TXA in G.I. bleeding requires cautious interpretation and individualized patient management, taking into account the potential benefits and risks of treatment 6.

Sub-Group Analysis

• Sub-group analysis suggests that TXA may be more effective in reducing bleeding and mortality in patients with upper G.I. bleeding, while its use in lower G.I. bleeding may be associated with a significant increase in mortality 6.
• The route of administration of TXA, whether oral or intravenous, may also impact its efficacy and safety in G.I. bleeding 6.