From the Guidelines
Tranexamic acid (TXA) should not be used to stop an upper GI bleed, particularly in patients with cirrhosis and variceal bleeding, as it has been shown to have no beneficial effect and may increase the risk of venous thromboembolic events 1.
Key Points
- The use of TXA in patients with cirrhosis and active variceal bleeding is not recommended, as stated in the EASL clinical practice guidelines 1.
- A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA in reducing mortality due to bleeding within the first 5 days, and an increased risk of venous thromboembolic events was observed in the TXA group 1.
- The mechanism of variceal bleeding is complex, and the use of antifibrinolytics like TXA may not be effective due to the limited role of hemostasis in variceal bleeding and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis 1.
Clinical Implications
- Standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, but TXA should not be used as part of this treatment regimen 1.
- In patients with cirrhosis and active bleeding related to portal hypertension, but not to varices, the use of TXA is not recommended, and correction of hemostatic abnormalities should be considered on a case-by-case basis 1.
- A restrictive red blood cell transfusion strategy is beneficial in patients with cirrhosis and variceal bleeding, as administration of large volumes of blood products may paradoxically increase bleeding rather than contribute to control of bleeding 1.
From the Research
Effectiveness of Tranexamic Acid in Upper GI Bleed
- Tranexamic acid (TXA) has been shown to be effective in reducing the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A pilot study found that TXA was beneficial as adjunctive therapy in treating major upper gastrointestinal bleeding in dialysis patients, decreasing the rate of early re-bleeding and the need for repeated endoscopic procedures 3.
- A systematic review and meta-analysis found that low-dose IV/enteral TXA reduced the risk of rebleeding and the need for surgery, but extended-use high-dose IV TXA did not improve mortality or bleeding outcomes and increased adverse events 4.
Comparison of TXA with Acid Suppression
- A meta-analysis of randomized controlled trials found that combining TXA with acid suppression significantly reduced the risk of rebleeding, units of blood transfused, and the need for salvage therapy in patients with upper gastrointestinal bleeding 5.
- The study suggests that combining TXA with acid suppression as a first-line therapy for upper GI bleed patients may be beneficial, but further trials are needed to determine the optimal dose and route of TXA administration 5.
Safety and Efficacy Concerns
- High-dose TXA has been associated with an increased risk of deep venous thrombosis, pulmonary embolism, and seizure 4.
- The optimal dose and timing of TXA administration to minimize the risk of seizures or thromboembolic events is still being researched 6.
- TXA has been found to be effective in reducing bleeding in various clinical indications, but its use in upper and lower gastrointestinal bleeding has shown mixed results 6.