From the Guidelines
Tranexamic acid (TXA) should not be used as a first-line therapy for gastrointestinal (GI) bleeding, as the evidence for its effectiveness is limited and it may increase the risk of thrombotic complications. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or re-bleeding rates in patients with cirrhosis and variceal bleeding, and actually increased the risk of venous thromboembolic events.
When considering the use of TXA in GI bleeding, it is essential to weigh the potential benefits against the risks, particularly in patients with a history of thromboembolism or renal impairment. The medication works as an antifibrinolytic agent, inhibiting plasminogen activation and preventing the breakdown of blood clots, but its effectiveness in GI bleeding is not well established.
Current practice generally favors other interventions, such as:
- Proton pump inhibitors for upper GI bleeding
- Endoscopic therapy
- Correction of coagulopathy These approaches have a stronger evidence base and are recommended as first-line treatments for GI bleeding. TXA may be considered as an adjunctive therapy in certain cases of severe bleeding, but its use should be carefully evaluated on a case-by-case basis, taking into account the potential risks and benefits.
In patients with hereditary hemorrhagic telangiectasia (HHT), TXA may be recommended for mild GI bleeding, but the evidence for its effectiveness is limited, and it is not recommended for moderate or severe GI bleeding 1. Similarly, in patients with acute lower gastrointestinal bleeding, the use of TXA is not recommended outside of clinical trials, pending the results of further studies 1.
In summary, while TXA may have a role in certain specific scenarios, its use in GI bleeding should be approached with caution, and other established treatments should be prioritized.
From the Research
Role of Tranexamic Acid in Treating Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been proposed as a treatment for gastrointestinal (GI) 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, particularly in patients with upper GI bleeding, with a reduction in the risk of death by 16% (OR=0.84,95% CI: 0.78 to 0.91, p<0.0001) 6.
- However, the results are not consistent across all studies, with some finding no significant difference in mortality or rebleeding rates between TXA and placebo 2, 5.
- TXA may increase the risk of venous thromboembolic events, with a pooled risk ratio of 1.94 (95% CI: 1.23-3.05) 5.
- The certainty of evidence for the different outcomes ranges from low to very low, highlighting the need for further high-quality research to fully understand the effects of TXA in GI bleeding 5.
Dosage and Administration
- The dosage and administration of TXA may impact its efficacy and safety, with high-dose IV TXA potentially increasing the risk of adverse events 2.
- Low-dose IV or enteral TXA may be effective in reducing rebleeding and the need for surgery, but more evidence is required to demonstrate its safety 2.
- Early administration of TXA, within 3 hours of bleeding onset, may be associated with a greater reduction in mortality (OR=0.80,95% CI: 0.73 to 0.88, p<0.0001) 6.
Clinical Implications
- The use of TXA in GI bleeding should be considered in the context of other relevant evidence, including its effects in other bleeding conditions 6.
- Clinicians should weigh the potential benefits and risks of TXA, including its impact on mortality, bleeding, and adverse events, when making treatment decisions 2, 3, 4, 5, 6.