From the Guidelines
Tranexamic acid (TXA) should not be used as a first-line treatment to stop a gastrointestinal (GI) bleed. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not have a beneficial effect in patients with acute upper gastrointestinal bleeding, and actually increased the risk of venous thromboembolic events. This study included over 12,000 patients and is the most robust evidence available on this topic.
Key Points to Consider
- The mechanism of action of TXA, which involves inhibiting plasminogen activation to prevent fibrin clot breakdown, may not be effective in addressing the complex nature of GI bleeding, which often requires direct intervention at the bleeding site.
- Current guidelines, as outlined in the 2022 Journal of Hepatology study 1, do not support the routine use of TXA in GI bleeding due to insufficient evidence of benefit and potential risks, including thrombotic complications.
- Standard treatments for acute GI bleeding include proton pump inhibitors, endoscopic interventions, and blood product transfusions as needed, and patients should be promptly assessed for hemodynamic stability and referred for urgent endoscopic evaluation.
- Other studies, such as the 2019 Gut study 1, have also found limited evidence to support the use of TXA in GI bleeding, and have highlighted the potential risks of thrombotic complications.
Clinical Implications
- Patients with GI bleeding should be managed with standard treatments, including proton pump inhibitors, endoscopic interventions, and blood product transfusions as needed.
- TXA should not be used as a first-line treatment for GI bleeding, and its use should be considered on a case-by-case basis, taking into account the potential risks and benefits.
- Clinicians should be aware of the latest evidence and guidelines, and should prioritize the use of evidence-based treatments to optimize patient outcomes.
From the Research
Tranexamic Acid (TXA) in Gastrointestinal (GI) Bleeding
- TXA is a synthetic antifibrinolytic drug that has been used to treat serious hemorrhage, including bleeding from major trauma and post-operative interventions 2.
- The efficacy of TXA in stopping a GI bleed has been studied in several randomized controlled trials, with varying results.
Efficacy of TXA in GI Bleeding
- A 2018 study found that early intravenous and/or intravenous plus topical administration of TXA reduced the need for urgent endoscopy for acute gastrointestinal bleeding 2.
- A 2021 systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 3.
- Another 2021 systematic review and meta-analysis found that TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 4.
- However, a 2020 meta-analysis found that TXA did not improve outcomes in acute upper GI bleeding and may increase the risk of venous thromboembolic events 5.
Safety of TXA in GI Bleeding
- The safety of TXA in GI bleeding has been a concern, with some studies reporting an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism 6, 5.
- A 2022 systematic review and meta-analysis found that extended-use high-dose IV TXA increased the risk of adverse events, including deep venous thrombosis, pulmonary embolism, and seizure 6.
Subgroup Analysis
- A subgroup analysis of patients with upper GI bleeding found that TXA may be effective in reducing rebleeding and the need for surgery, but not mortality or thromboembolic events 4.
- Another subgroup analysis found that low-dose IV/enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 6.