From the Guidelines
Tranexamic acid (TXA) should not be used to stop a GI bleed 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 GI bleeding is still a topic of debate, and its effectiveness varies depending on the underlying cause of the bleed. According to the most recent and highest quality study 1, TXA has been evaluated in a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding, and no beneficial effect was observed in the whole group or in the subgroup analysis of patients with suspected variceal bleeding and liver disease comorbidity.
In patients with hereditary hemorrhagic telangiectasia (HHT), TXA is recommended for patients with mild GI bleeding on the basis of low potential for harm, but there is limited evidence of effectiveness 1. However, this recommendation is specific to HHT patients and may not be applicable to other causes of GI bleeding.
In general, the use of TXA in GI bleeding should be cautious and considered on a case-by-case basis, taking into account the underlying cause of the bleed, the severity of the bleeding, and the patient's individual risk factors for thromboembolic events. Other treatments, such as endoscopic interventions, proton pump inhibitors, and blood product transfusions, should be prioritized, and TXA should only be used as an adjunctive therapy when necessary.
It's also important to note that TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites in the GI tract, but it does not replace the need for definitive treatment of the underlying cause of GI bleeding. Potential side effects of TXA include nausea, vomiting, and a theoretical risk of thromboembolism, though this risk appears low in clinical practice. TXA should be used cautiously in patients with a history of thromboembolic disease or severe renal impairment.
In summary, while TXA may have a role in certain cases of GI bleeding, its use should be carefully considered and individualized, and it should not be used as a first-line treatment for GI bleeding in patients with cirrhosis and active variceal bleeding.
From the Research
Role of Tranexamic Acid in Treating GI Bleeding
- Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that has been studied for its effectiveness in treating gastrointestinal (GI) bleeding 2, 3, 4, 5, 6.
- The evidence suggests that TXA may be effective in reducing the risk of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 4, 5.
- However, the results are not consistent across all studies, and some have found no significant difference in outcomes between TXA and placebo or usual care 3, 6.
- The use of high-dose IV TXA has been associated with an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism 3, 6.
Efficacy of TXA in GI Bleeding
- A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 4.
- Another study found that TXA did not reduce mortality or bleeding outcomes, but may be effective in reducing the need for urgent endoscopy 2.
- A meta-analysis of randomized controlled trials found that TXA did not improve outcomes in acute upper GI bleeding and may increase the risk of venous thromboembolic events 6.
Safety of TXA in GI Bleeding
- The safety of TXA in patients with GI bleeding has been evaluated in several studies, with some finding no significant increase in adverse events 2, 5.
- However, other studies have found an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism, with the use of high-dose IV TXA 3, 6.
- The certainty of evidence for the safety of TXA in GI bleeding is generally considered low to very low due to the limited number of studies and the variability in results 6.