From the Guidelines
Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, as the most recent and highest quality evidence suggests it does not provide a significant benefit in reducing mortality or re-bleeding rates, and may even increase the risk of venous thromboembolic events. 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 death due to bleeding within the first 5 days. 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 primary treatments for GI bleeding typically include:
- Proton pump inhibitors (like pantoprazole 40mg IV twice daily)
- Endoscopic interventions to directly treat the bleeding source
- Supportive care with IV fluids and blood products as needed TXA may be considered in specific scenarios, such as bleeding related to coagulopathies or when endoscopic treatment is delayed or unsuccessful, but its use should be carefully weighed against the potential risks. The medication works by preventing plasmin from degrading fibrin clots, thereby stabilizing any clots that have formed at the bleeding site. However, the latest evidence from the Journal of Hepatology study 1 suggests that TXA is not effective in variceal bleeding and may even be harmful, which is consistent with the guidelines from the British Society of Gastroenterology 1 that suggest the use of TXA in acute LGIB should be confined to clinical trials.
Key points to consider when managing GI bleeding include:
- The importance of prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment
- The potential risks and benefits of correcting haemostatic abnormalities, such as thrombocytopenia or coagulopathy
- The need for a comprehensive approach to GI bleeding management, including supportive care and monitoring for potential complications.
From the Research
Effectiveness of Tranexamic Acid in GI Bleeding
- Tranexamic acid (TXA) has been shown to reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A double-blind randomized controlled trial found that early intravenous and/or intravenous plus topical administration of TXA reduces the need for urgent endoscopy for acute gastrointestinal bleeding 3.
- The HALT-IT trial aims to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding, with primary outcomes including death due to bleeding within 5 days of randomization and secondary outcomes such as rebleeding and thromboembolic events 4.
Upper GI Bleeding
- A systematic review of randomized trials on TXA for upper gastrointestinal bleeding found that TXA may reduce all-cause mortality, but additional evidence is needed before treatment recommendations can be made 5.
- Another study found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
Lower GI Bleeding
- A double-blind prospective randomized controlled trial found that intravenous TXA has no significant effect on blood requirement in patients with lower GI bleeding 6.
- The HALT-IT trial also aims to investigate the effects of TXA on lower GI bleeding, but the results are not yet available 4.