From the Guidelines
Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, as the most recent and highest quality evidence does not support its effectiveness in this context. According to the study published in the Journal of Hepatology in 2022 1, a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of tranexamic acid in reducing mortality due to bleeding. Furthermore, the study reported an almost 2-fold increase in the incidence of venous thromboembolic events in the tranexamic acid group compared to the placebo group.
The mechanism of action of TXA, which involves inhibiting plasminogen activation to prevent the breakdown of fibrin clots, may not adequately address the complex causes of GI bleeding, which often require direct intervention at the bleeding site. Standard treatments for acute GI bleeding include proton pump inhibitors, endoscopic interventions, vasopressors like octreotide (for variceal bleeding), and blood product transfusions as needed.
Key points to consider:
- The British Society of Gastroenterology guidelines suggest that the use of tranexamic acid in acute lower gastrointestinal bleeding should be confined to clinical trials, pending the results of the HALT-IT trial 1.
- The EASL clinical practice guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis strongly recommend against the use of tranexamic acid in patients with cirrhosis and active variceal bleeding 1.
- The potential risks of thromboembolic complications associated with TXA use in certain patients, particularly those with comorbid liver disease or suspected variceal bleeding, should be carefully considered.
From the Research
Effectiveness of Tranexamic Acid (TXA) in Stopping GI Bleed
- The effectiveness of TXA in stopping GI bleed is a topic of ongoing research, with studies yielding mixed results 2, 3, 4, 5, 6.
- A study published in 2021 found that TXA had no significant positive effect on patients with upper gastrointestinal bleeding 2.
- In contrast, 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 gastrointestinal bleeding 3.
- Another study published in 2008 found that TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding, but the evidence was limited by the quality of the included trials 4.
- A randomized controlled trial published in 2024 found that TXA had no significant effect on blood transfusion requirements in patients with lower gastrointestinal bleeding 5.
- A pilot study published in 2003 found that TXA was beneficial as adjunctive therapy in treating major upper gastrointestinal bleeding in dialysis patients, reducing the rate of early re-bleeding and the need for blood transfusions 6.
Upper vs. Lower GI Bleed
- The effectiveness of TXA may vary depending on the location of the GI bleed, with some studies suggesting that it is more effective in upper GI bleeding 3, 4, 6.
- In contrast, a study published in 2024 found that TXA had no significant effect on blood transfusion requirements in patients with lower gastrointestinal bleeding 5.
Clinical Implications
- The use of TXA in GI bleeding should be considered on a case-by-case basis, taking into account the severity of the bleeding, the location of the bleed, and the patient's underlying medical conditions 2, 3, 4, 5, 6.
- Further research is needed to fully understand the effectiveness of TXA in stopping GI bleed and to determine the optimal dosage and duration of treatment 2, 3, 4, 5, 6.