From the Guidelines
Tranexamic acid (TXA) should not be used as a first-line treatment for gastrointestinal (GI) bleeding, and its use is generally not recommended due to the lack of strong evidence supporting its effectiveness and the potential risk of thromboembolic events. For upper GI bleeds, the use of TXA has been evaluated in several studies, but the most recent and highest quality study, published in 2022 1, found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, and actually reported an increased incidence of venous thromboembolic events in the TXA group. The study suggests that the use of TXA in GI bleeding may be harmful, particularly in patients with comorbid liver disease or suspected variceal bleeding.
The mechanism of action of TXA involves inhibiting fibrinolysis, which can promote clot stability and reduce bleeding, but this effect may not be sufficient to outweigh the risks of thromboembolic events. The British Society of Gastroenterology guidelines, published in 2019 1, suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial.
In certain situations, such as hereditary hemorrhagic telangiectasia (HHT), TXA may be considered for patients with mild GI bleeding, but the evidence for its effectiveness is limited, and other systemic therapies, such as bevacizumab, may be more effective for patients with moderate or severe GI bleeding 1.
In summary, the use of TXA in GI bleeding is not supported by strong evidence, and its potential risks, including thromboembolic events, should be carefully considered before administering the medication. The decision to use TXA in GI bleeding should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of the medication.
From the Research
Efficacy of Tranexamic Acid in Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with some studies suggesting its efficacy in reducing bleeding and mortality rates 2, 3, 4, 5.
- A double-blind randomized controlled trial published in 2018 found that TXA reduced the need for urgent endoscopy in patients with acute GI bleeding, with no significant differences in mortality, re-bleeding, or blood transfusion rates 2.
- 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 3.
- Another systematic review and meta-analysis published in 2022 found that low-dose IV/enteral TXA reduced the risk of rebleeding and need for surgery, but extended-use high-dose IV TXA did not improve mortality or bleeding outcomes and increased adverse events 6.
- A population-based cohort study published in 2022 found that early TXA treatment was associated with a reduced risk of mortality in patients with GI bleeding, without an increase in thromboembolic events 4.
Safety and Adverse Events
- The studies reviewed found no significant increase in thromboembolic events with TXA treatment 2, 4, 5.
- However, one study found that extended-use high-dose IV TXA resulted in a small increase in deep venous thrombosis, pulmonary embolism, and seizure 6.
- Adverse events were unclearly reported in some studies, highlighting the need for further research on the safety of TXA in GI bleeding 5.
Clinical Implications
- The available evidence suggests that TXA may be an effective treatment for upper GI bleeding, particularly when administered early 3, 4.
- However, the optimal dosing strategy and potential risks and benefits of TXA in GI bleeding require further clarification 6.
- Additional randomized clinical trials are needed to fully establish the efficacy and safety of TXA in GI bleeding 2, 3, 4, 5.