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 [ 1 ]. The use of TXA in GI bleeding has been evaluated in several studies, but the results have been inconsistent and often conflicting. A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA in reducing mortality due to bleeding [ 1 ]. Furthermore, the trial reported an increased incidence of venous thromboembolic events in the TXA group, particularly in patients with comorbid liver disease or suspected variceal bleeding.
Some key points to consider when managing GI bleeding include:
- The standard approach for upper GI bleeds typically involves proton pump inhibitors, endoscopic intervention, and blood product resuscitation as needed.
- For lower GI bleeds, management may involve colonoscopy, angiography with embolization, or surgery depending on severity and location.
- TXA might be considered as an adjunctive therapy in specific cases where standard treatments have failed or are unavailable, but it should not replace established interventions.
- The medication works by preventing the breakdown of fibrin clots, but this mechanism has not consistently translated to improved outcomes in GI bleeding, unlike its proven benefits in trauma and surgical bleeding [ 1 ].
In patients with cirrhosis and active variceal bleeding, the guidelines recommend against the use of TXA [ 1 ]. Instead, treatment should focus on prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment. The use of blood products, such as platelets and fresh frozen plasma, should be considered on a case-by-case basis, taking into account the patient's individual risk factors and the potential for thromboembolic events.
From the Research
Effectiveness 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 pilot study found that TXA was beneficial in treating major upper gastrointestinal bleeding in dialysis patients, reducing the rate of early re-bleeding, repeated endoscopic procedures, and blood transfusions needed 3.
- A systematic review suggested that TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding, but the evidence was limited by the internal and external validity of the included trials 4.
- Another systematic review and meta-analysis found that extended-use high-dose IV TXA did not improve mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 5.
- A large randomized controlled trial found that TXA did not reduce death from gastrointestinal bleeding and was not cost-effective in adults with acute gastrointestinal bleeding 6.
Key Findings
- TXA may be effective in reducing bleeding and mortality in patients with upper gastrointestinal bleeding, but the evidence is not consistent across all studies.
- The effectiveness of TXA in lower gastrointestinal bleeding is less clear and requires further clarification.
- High-dose IV TXA may increase the risk of thromboembolic events, such as deep-vein thrombosis and pulmonary embolism.
- Low-dose IV/enteral TXA may be a safer and more effective option for reducing hemorrhage in patients with gastrointestinal bleeding.