What is the role of tranexamic acid (TXA) in managing gastrointestinal (GI) bleeding?

From the Guidelines

Tranexamic acid (TXA) should not be used as a standard treatment for gastrointestinal (GI) bleeding outside of clinical trials, due to uncertain benefits and potential risks, as evidenced by the lack of clear mortality benefit in low-risk bias trials 1. When considering the management of GI bleeding, the primary focus should be on established treatments such as proton pump inhibitors, endoscopic interventions, and blood product support.

• The use of TXA in acute GI bleeding has been explored in several trials, which initially suggested a 40% risk reduction in mortality 1.
• However, when the analysis was limited to trials at low risk of bias, this treatment benefit for mortality was no longer apparent 1.
• Furthermore, the studies were considered historic and were conducted before the routine use of high-dose acid suppression and endoscopic therapy, making their extrapolation to modern day care uncertain 1.
• The potential risks of TXA, including thromboembolic events, also warrant caution in its use, particularly in patients with a history of thrombosis or active thromboembolic disease.
• As such, the current guidelines suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of further studies such as the HALT-IT trial 1.

From the Research

Role of Tranexamic Acid in GI Bleeding

• Tranexamic acid (TXA) has been studied for its potential to manage gastrointestinal (GI) bleeding, with varying results across different studies 2, 3, 4, 5, 6.
• A systematic review and meta-analysis published in 2021 found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 2.
• Another study published in 2022 found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 3.
• A 2014 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 4.
• A 2020 meta-analysis found no significant difference in mortality, rebleeding, or need for surgery between TXA and placebo in acute upper GI bleeding, but an increased risk of venous thromboembolic events with TXA 5.
• A 2023 systematic review and individual patient data meta-analysis found that TXA reduced the odds of death by 16% in patients with GI bleeding, and did not increase the odds of vascular occlusive events 6.

Efficacy of TXA in GI Bleeding

• The efficacy of TXA in GI bleeding is still unclear, with some studies showing a benefit and others showing no effect 2, 3, 4, 5, 6.
• The timing of TXA administration may be important, with one study finding that TXA reduced the odds of death by 20% in patients treated within 3 hours of bleeding onset 6.
• The dose and route of TXA administration may also be important, with some studies suggesting that low-dose IV/enteral TXA may be more effective than high-dose IV TXA 3.

Safety of TXA in GI Bleeding

• The safety of TXA in GI bleeding is a concern, with some studies reporting an increased risk of venous thromboembolic events 3, 5.
• However, other studies have found no increase in vascular occlusive events with TXA 6.
• The overall safety profile of TXA in GI bleeding needs to be carefully considered, taking into account the potential benefits and risks of treatment 2, 3, 4, 5, 6.