What is the role of Tranexamic acid (TXA) in the treatment of esophageal varices?

From the Guidelines

Tranexamic acid (TXA) should not be used in the treatment of esophageal varices. The most recent and highest quality evidence, as outlined in the EASL clinical practice guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis 1, strongly recommends against the use of TXA in patients with cirrhosis and active variceal bleeding, citing a lack of beneficial effect and potential increased risk of venous thromboembolic events.

The standard treatment approach for acute variceal bleeding includes vasoactive medications, endoscopic therapy, and antibiotics. The use of TXA as an adjunctive therapy is not supported by current evidence, and its potential risks, including thrombotic complications, outweigh any theoretical benefits.

Key points to consider in the management of esophageal varices include:

• The primary treatment for esophageal variceal bleeding is the combination of endoscopic variceal ligation (EVL) plus non-selective beta blockers (NSBBs) 1
• TIPS placement should be considered as a rescue therapy if primary treatment for esophageal variceal rebleeding fails 1
• Liver transplantation might be considered in patients with recurrent variceal rebleeding 1

In summary, the focus of treatment for esophageal varices should be on reducing portal pressure and addressing the underlying liver disease, rather than the use of antifibrinolytic agents like TXA.

From the Research

Role of Tranexamic Acid in Esophageal Varices

• Tranexamic acid (TXA) is an antifibrinolytic agent that has been studied for its potential role in treating esophageal varices, a major complication of portal hypertension 2.
• A randomized controlled trial published in 2024 found that TXA significantly reduced the failure to control bleeding by day 5 and failure to prevent rebleeding after day 5 to 6 weeks in patients with advanced liver cirrhosis presenting with upper gastrointestinal bleeding 3.
• The study also found that TXA reduced the failure to control bleeding from the esophageal endoscopic variceal ligation (EVL) site, which is a common source of bleeding in patients with esophageal varices 3.

Mechanism of Action

• TXA works by inhibiting the breakdown of fibrin clots, which helps to stop bleeding and prevent rebleeding 4.
• The drug has been shown to be effective in reducing bleeding in various clinical contexts, including postpartum hemorrhage and trauma 4.

Efficacy and Safety

• A systematic review and meta-analysis published in 2022 found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes in patients with gastrointestinal bleeding, but increased the risk of adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 5.
• However, low-dose IV or enteral TXA may be effective in reducing rebleeding and the need for surgery, although more evidence is required to demonstrate its safety 5.
• Another study published in 2000 discussed the role of vasoactive drugs, including vasopressin and somatostatin, in controlling acute bleeding from gastric and esophageal varices, but did not mention TXA specifically 6.

Clinical Context

• The use of TXA in esophageal varices is still a topic of ongoing research, and its efficacy and safety profile may vary depending on the clinical context and patient population 3, 4, 5.
• Further studies are needed to fully understand the role of TXA in the treatment of esophageal varices and to determine its optimal dosing and administration regimen 3, 4, 5.