From the Guidelines
Tranexamic acid (TXA) should not be relied upon as a primary treatment to stop a gastrointestinal (GI) bleed due to limited and conflicting evidence of its effectiveness in this context. While TXA is an antifibrinolytic agent that can help prevent blood clot breakdown, its use in GI bleeds is not well-supported by current evidence. For patients with hereditary hemorrhagic telangiectasia (HHT), TXA is recommended for those with mild GI bleeding due to its low potential for harm, but its effectiveness is not well-established 1. In other cases of GI bleeding, standard treatments such as proton pump inhibitors, endoscopic interventions, and vasopressors are preferred. The mechanism of TXA, which involves inhibiting plasminogen activation to prevent fibrin clot breakdown, may not adequately address the complex pathophysiology of GI bleeding, which often requires direct intervention at the bleeding site.
Some studies have suggested a potential benefit of TXA in reducing mortality from GI bleeding, but these findings are not consistent across all research and may be influenced by the quality of the studies and the specific patient populations examined 1. Given the limited and conflicting evidence, the use of TXA in acute GI bleeding should be approached with caution and considered on a case-by-case basis, with a focus on hemodynamic stabilization, identifying the bleeding source, and implementing cause-specific treatments. It's also important to note that the British Society of Gastroenterology suggests confining the use of TXA in acute lower gastrointestinal bleeding to clinical trials, pending further research 1.
Key considerations in managing GI bleeding include:
- Hemodynamic stabilization
- Identifying the bleeding source
- Implementing cause-specific treatments, such as proton pump inhibitors for ulcer bleeding or vasopressors for variceal bleeding
- Endoscopic interventions or interventional radiology procedures as needed
- The potential role of TXA in specific cases, such as mild GI bleeding in patients with HHT, but with awareness of its limited evidence base.
From the Research
Efficacy of Tranexamic Acid (TXA) in Stopping GI Bleed
- 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 systematic review and meta-analysis found that TXA significantly reduced rebleeding rates overall, with a more pronounced effect in studies with a lower risk of bias 3.
- TXA use was associated with a mortality reduction when administered through both oral and intravenous routes, and in cases of upper GI bleeding 3.
Reduction in Urgent Endoscopy and Surgical Intervention
- The antifibrinolytic properties of TXA can aid in changing an urgent endoscopy to an elective procedure, with better outcomes for both physicians and patients 4.
- A systematic review and meta-analysis found that TXA significantly reduced the need for surgical intervention when excluding high-risk of bias studies 3.
- TXA was also found to reduce the need for surgery in patients with upper GI bleeding, with a statistically significant risk ratio of 0.59 5.
Safety and Adverse Events
- Extended-use high-dose IV TXA was found to increase the risk of deep venous thrombosis, pulmonary embolism, and seizure, with high certainty 6.
- However, low-dose IV/enteral TXA did not reduce mortality but did reduce the risk of rebleeding and need for surgery, with moderate certainty 6.
- A systematic review and meta-analysis found no definitive evidence that TXA use is associated with thromboembolic events, but highlighted the need for cautious interpretation and individualized patient management 3.