From the Guidelines
Tranexamic acid (TXA) should not be used as a primary treatment to stop a gastrointestinal (GI) bleed, especially in patients with cirrhosis and variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in certain clinical scenarios 1. However, the most recent and highest quality study 1 found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity. In fact, the study reported an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group.
Some key points to consider when evaluating the use of TXA in GI bleeding include:
- The mechanism of action of TXA, which involves inhibiting fibrinolysis and stabilizing blood clots 1
- The potential risks of thrombotic complications, particularly in patients with a history of thromboembolism 1
- The importance of prompt endoscopic evaluation and intervention in patients with active, severe GI bleeding 1
- The lack of beneficial effect of TXA in patients with cirrhosis and variceal bleeding, and the potential for increased risk of thromboembolic events 1
In terms of specific treatment protocols, the evidence suggests that TXA should not be used as a primary treatment for GI bleeding, especially in patients with cirrhosis and variceal bleeding. Instead, treatment should focus on prompt endoscopic evaluation and intervention, as well as the use of other standard therapies such as proton pump inhibitors and vasopressors. The use of TXA should be limited to clinical trials or specific clinical scenarios where the potential benefits outweigh the risks, and should always be carefully considered on a case-by-case basis 1.
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.