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 bleeding is not strongly supported by current guidelines 1. The mechanism of TXA, which involves inhibiting plasminogen activation to prevent fibrin clot breakdown, may not adequately address the complex nature of GI bleeding, which often requires direct intervention at the bleeding site.
For patients with hereditary hemorrhagic telangiectasia (HHT) and GI bleeding, systemic therapies are recommended as the primary modality for managing GI bleeding, with TXA suggested for patients with mild GI bleeding due to its low potential for harm, but with limited evidence of effectiveness 1. However, for acute GI bleeding in general, standard treatments include proton pump inhibitors, endoscopic interventions, and blood product transfusions as needed, rather than TXA. Some studies have explored TXA use in GI bleeding, but the evidence is not sufficient to support its routine use due to insufficient data showing a mortality benefit, especially when considering the results of more recent and higher-quality studies 1.
Key considerations in managing GI bleeding include:
- Hemodynamic stabilization
- Identifying the bleeding source through endoscopy
- Applying appropriate direct hemostatic measures
- Use of proton pump inhibitors and other standard treatments as indicated TXA may be considered in specific contexts, such as clinical trials or where its use is part of a broader treatment protocol, but it should not be the primary reliance for stopping a GI bleed given the current state of evidence 1.
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 the risk of rebleeding and the need for surgery in patients with upper GI bleeding 3.
- Another study found that TXA can aid in changing an urgent endoscopy to an elective procedure, with better outcomes for both physicians and patients 4.
Mechanism of Action and Dosage
- TXA is a synthetic antifibrinolytic drug that works by inhibiting the breakdown of fibrin clots, thereby reducing bleeding 4.
- The optimal dosage of TXA for GI bleeding is still unclear, with some studies using high-dose IV TXA and others using low-dose IV or enteral TXA 5.
Safety and Adverse Events
- High-dose IV TXA has been associated with an increased risk of deep venous thrombosis, pulmonary embolism, and seizure 5.
- Low-dose IV or enteral TXA may be safer, but more evidence is needed to demonstrate its safety 5.
- One study found that TXA was more often prescribed to patients with more severe GI bleeding ulcer disease, and these patients were more likely to need blood transfusions and have longer hospital stays 6.
Clinical Implications
- The use of TXA in upper GI bleeding may be beneficial in reducing the risk of rebleeding and the need for surgery 3.
- However, the evidence is still limited, and more studies are needed to fully understand the effects of TXA in GI bleeding 2, 5, 3.
- Clinicians should carefully consider the potential benefits and risks of TXA in patients with GI bleeding, and more research is needed to determine the optimal dosage and treatment strategy 4, 5.