From the Guidelines
Tranexamic acid (TXA) should not be used to stop an upper gastrointestinal (GI) bleed, particularly in patients with cirrhosis and variceal bleeding, due to the lack of beneficial effect and potential increased risk of venous thromboembolic events 1.
Key Points
- The use of TXA in upper GI bleeding has been evaluated in a large randomized placebo-controlled trial, which found no beneficial effect of TXA in reducing mortality due to bleeding within the first 5 days 1.
- In patients with cirrhosis and active variceal bleeding, the guidelines strongly recommend against the use of TXA (LoE 2, strong recommendation) 1.
- The primary management of upper GI bleeds remains prompt endoscopic evaluation and intervention to directly identify and treat the bleeding source.
- Standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, with a focus on reducing portal pressure and preventing re-bleeding 1.
Considerations
- The mechanism of TXA involves preventing the breakdown of fibrin clots, but it does not directly address the underlying cause of bleeding such as peptic ulcers or varices.
- The use of TXA may be associated with an increased risk of venous thromboembolic events, particularly in patients with comorbid liver disease or suspected variceal bleeding 1.
- A restrictive red blood cell transfusion strategy is beneficial in patients with cirrhosis and active 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) may reduce upper gastrointestinal bleeding and stabilize patients before endoscopic treatments 2.
- A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 3.
- However, another study found no significant positive effect of TXA in patients with upper gastrointestinal bleeding, suggesting that the difference between the two groups may be due to the severity of the condition rather than the drug effect 4.
Comparison with Other Treatments
- A review of randomized trials found that TXA reduced mortality compared to placebo, but the beneficial effect was not confirmed in subgroup analysis or in trials using endoscopic therapy 5.
- Pharmacotherapy, including acid suppression and vasoactive agents, is an important adjunct to endoscopic hemostasis in the management of upper gastrointestinal bleeding 6.