From the Guidelines
Tranexamic acid should not be used in patients with upper gastrointestinal (GI) bleeding, particularly in those with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and potential increased risk of venous thromboembolic events 1.
Rationale
The use of tranexamic acid in managing upper GI bleeding has been evaluated in several studies, with the most recent and highest quality study being a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding 1. This study found no beneficial effect of tranexamic acid in reducing death due to bleeding within the first 5 days, and a subgroup analysis of patients with suspected variceal bleeding and liver disease comorbidity also showed no benefit. 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, particularly in patients with comorbid liver disease/suspected variceal bleeding.
Key Points
- Tranexamic acid is not recommended for patients with cirrhosis and active variceal bleeding due to the lack of beneficial effect and potential increased risk of venous thromboembolic events 1.
- The use of tranexamic acid may be associated with an increased risk of thrombotic events, particularly in patients with comorbid liver disease/suspected variceal bleeding 1.
- Standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, with a restrictive red blood cell transfusion strategy being beneficial in reducing re-bleeding and mortality 1.
Clinical Implications
In clinical practice, the management of upper GI bleeding should focus on standard therapy, including vasoactive therapy, antibiotics, and endoscopic treatment, rather than the use of tranexamic acid. Patients with cirrhosis and active variceal bleeding should be managed on a case-by-case basis, with consideration of the potential risks and benefits of correcting haemostatic abnormalities 1.
From the Research
Role of Tranexamic Acid in Upper GI Bleeding
- Tranexamic acid (TXA) has been studied for its potential to reduce mortality and hemorrhage in upper gastrointestinal (GI) bleeding 2, 3, 4, 5.
- The mechanism of action of TXA involves inhibiting the breakdown of fibrin clots by plasmin, thereby reducing bleeding 6.
- Studies have shown that TXA may reduce all-cause mortality in patients with upper GI bleeding, with a relative risk (RR) of 0.61 (95% CI 0.42-0.89) 2 and 0.59 (95% CI 0.43-0.82) 5.
- TXA has also been found to reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo, with an RR of 0.60 (95% CI 0.43-0.84) for continued bleeding and 0.60 (95% CI 0.45-0.80) for mortality 4.
Efficacy and Safety of TXA
- The efficacy and safety of TXA in GI bleeding are uncertain due to methodological weaknesses and small size of existing trials 6.
- The HALT-IT trial, a large international randomized controlled trial, aims to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding 6.
- Meta-analyses have found no significant differences between TXA and placebo for the prevention of re-bleeding, need for surgical interventions, need for blood transfusions, or frequency of thromboembolic events 2, 3, 5.
- The quality of evidence for mortality has been rated as moderate due to risk of bias, and additional higher-quality trials are needed to confirm the findings 5.
Clinical Implications
- Early administration of TXA may be worth recommending for treating upper GI bleeding in the emergency department 4.
- The effects of TXA on lower GI bleeding warrant further clarification 4.
- TXA may be effective for reducing mortality in upper GI bleeding, but its use should be considered in the context of individual patient needs and existing clinical guidelines 2, 3, 5.