From the Guidelines
Tranexamic acid (TXA) should not be used as a primary treatment to stop a gastrointestinal (GI) bleed. While TXA is an antifibrinolytic agent that helps prevent blood clot breakdown and is effective for certain types of bleeding, evidence for its use in GI bleeds is limited and conflicting. According to the most recent and highest quality study 1, TXA did not show a beneficial effect in patients with acute upper gastrointestinal bleeding, and its use was associated with an increased risk of venous thromboembolic events. For acute GI bleeding, standard treatments include proton pump inhibitors, endoscopic interventions, and blood product transfusions as needed. TXA works by inhibiting plasminogen activation, which prevents the breakdown of fibrin clots, but this mechanism may not adequately address the complex nature of GI bleeding, which often requires direct intervention at the bleeding site.
Some key points to consider when managing GI bleeding include:
- Hemodynamic stabilization
- Identifying the bleeding source through endoscopy
- Applying appropriate direct hemostatic measures
- Using proton pump inhibitors, such as pantoprazole 40mg IV twice daily, as needed
- Considering blood product transfusions as needed
It's also important to note that the use of TXA in GI bleeding has been evaluated in several studies, but the results have been inconsistent. A large randomized placebo-controlled trial 1 found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, and another study 1 suggested that TXA may not be effective in GI bleeding due to the limited role of hemostasis in this type of bleeding.
In patients with cirrhosis and active variceal bleeding, the use of TXA is not recommended 1, and instead, portal hypertension-lowering drugs and endoscopic treatment should be used to achieve hemostasis. In cases where bleeding is not controlled, the decision to correct hemostasis should be considered on a case-by-case basis.
Overall, while TXA may have a role in certain types of bleeding, its use in GI bleeding is not supported by strong evidence, and other treatment options should be prioritized.
From the Research
Effectiveness of Tranexamic Acid (TXA) in Stopping GI Bleed
- TXA has been shown to reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A systematic review and meta-analysis found that TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding, but the evidence is limited and more research is needed 3.
- Another study 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 4.
- A systematic review and meta-analysis found that TXA appears to have a beneficial effect in terms of decreasing the risk of re-bleeding and decreasing the need for surgery in upper GI bleeding, but the effect on mortality is not statistically significant 5.
- A Cochrane review found that TXA appears to have a beneficial effect on mortality, but the evidence is not conclusive due to high dropout rates in some trials 6.
Key Findings
- TXA reduces the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding.
- Low-dose IV/enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety.
- TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding, but the evidence is limited and more research is needed.
- The effect of TXA on lower gastrointestinal bleeding warrants further clarification.
Outcomes
- Mortality: TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding, but the evidence is limited and more research is needed 3, 5, 6.
- Rebleeding: TXA appears to have a beneficial effect in terms of decreasing the risk of re-bleeding in upper GI bleeding 5.
- Need for surgery: TXA may reduce the need for surgery in upper GI bleeding 5, 6.
- Adverse events: Extended-use high-dose IV TXA may increase the risk of deep venous thrombosis, pulmonary embolism, and seizure 4.