From the Guidelines
Tranexamic acid (TXA) should not be used as a primary 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 incidence of venous thromboembolic events. This study included 12,009 patients and found no reduction in mortality or rebleeding rates with TXA use.
The mechanism of TXA, which inhibits plasminogen activation and prevents fibrin clot breakdown, may not be effective in addressing the complex nature of GI bleeding, which often requires direct intervention at the bleeding site. Standard treatments for acute GI bleeding include proton pump inhibitors, endoscopic interventions, and blood product transfusions as needed.
Some studies have suggested that TXA may have a benefit in certain types of bleeding, such as trauma 1, but this benefit has not been consistently shown in GI bleeding. In fact, the 2022 study 1 found that TXA may actually increase the risk of thromboembolic events in patients with liver disease and suspected variceal bleeding.
Therefore, when managing a GI bleed, it is recommended to focus on hemodynamic stabilization, early endoscopy, and treating the underlying cause, rather than relying on TXA as a primary intervention. Key considerations in GI bleed management include:
- Hemodynamic stabilization
- Early endoscopy
- Treating the underlying cause
- Use of proton pump inhibitors and other standard treatments as needed
- Avoidance of TXA as a primary treatment due to lack of benefit and potential increased risk of thromboembolic events.
From the Research
Tranexamic Acid (TXA) for Gastrointestinal (GI) Bleeding
- TXA is a synthetic antifibrinolytic drug that has been shown to be effective in treating serious hemorrhage, including bleeding from major trauma and post-operative interventions 2.
- The use of TXA in GI bleeding has been studied in several trials, with mixed results.
Efficacy of TXA in GI Bleeding
- A 2018 double-blind randomized controlled trial found that TXA reduced the need for urgent endoscopy in patients with acute GI bleeding, but did not significantly reduce mortality, re-bleeding, or blood transfusion rates 2.
- A 2021 systematic review and meta-analysis of randomized clinical trials found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 3.
- However, a 2020 international randomized, double-blind, placebo-controlled trial found that TXA did not reduce death from GI bleeding, and may even increase the risk of venous thromboembolic events 4.
TXA in Lower GI Bleeding
- A 2024 double-blind prospective randomized controlled trial found that intravenous TXA had no significant effect on blood transfusion requirements in patients with lower GI bleeding 5.
- The results of this trial suggest that TXA may not be effective in reducing blood transfusion requirements in patients with lower GI bleeding.
Summary of Findings
- The evidence for the use of TXA in GI bleeding is mixed, with some trials showing a benefit in reducing bleeding and mortality, while others show no significant effect.
- TXA may be effective in reducing bleeding and mortality in patients with upper GI bleeding, but its use in lower GI bleeding is less clear.
- Further research is needed to fully understand the efficacy and safety of TXA in GI bleeding, particularly in lower GI bleeding 3, 4, 5.