Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, particularly in cases of variceal bleeding, due to the lack of benefit and potential increased risk of thromboembolic events. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, and actually increased the risk of venous thromboembolic events. This study included a large randomized controlled trial of 12,009 patients, which provides strong evidence against the use of TXA in this context.

When considering the use of TXA in GI bleeding, it's essential to distinguish between different types of bleeding, such as variceal and non-variceal bleeding. The evidence suggests that TXA is not effective in variceal bleeding, which is a common cause of GI bleeding in patients with cirrhosis. In fact, the 2022 study found that TXA may even be harmful in this population, with an increased risk of thromboembolic events 1.

In contrast, the evidence for TXA in non-variceal bleeding is less clear, and more research is needed to determine its potential benefits and risks. However, based on the current evidence, TXA should not be used as a first-line treatment for GI bleeding, and its use should be limited to specific cases where the benefits outweigh the risks. Instead, standard treatments such as endoscopic intervention, proton pump inhibitors, and correction of coagulopathy should be prioritized.

It's also important to note that the British Society of Gastroenterology guidelines, published in 2019, suggest that TXA may be beneficial in acute GI bleeding, but this recommendation is based on older studies and has been superseded by the more recent evidence from the 2022 study 1. Therefore, the most up-to-date and highest quality evidence should be prioritized when making treatment decisions.

In summary, TXA should not be used to stop a GI bleed, particularly in cases of variceal bleeding, due to the lack of benefit and potential increased risk of thromboembolic events. Instead, standard treatments should be prioritized, and the use of TXA should be limited to specific cases where the benefits outweigh the risks.

From the Research

Effectiveness of Tranexamic Acid in Gastrointestinal Bleeding

• Tranexamic acid (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 study found that early administration of TXA may be worth recommending for treating upper gastrointestinal bleeding in the emergency department 2.
• Another study found that TXA can aid in changing an urgent endoscopy to an elective procedure, with better outcomes for both physicians and patients 3.

Upper Gastrointestinal Bleeding

• TXA may reduce upper gastrointestinal bleeding and stabilize patients before endoscopic treatments 4.
• A systematic review suggested that TXA may reduce all-cause mortality in upper gastrointestinal bleeding, but additional evidence is needed before treatment recommendations can be made 4.

Lower Gastrointestinal Bleeding

• A study found that intravenous TXA has no significant effect on blood requirement in patients with lower GI bleeding 5.
• There was no difference in the consumption of packed red blood cells units among patients in the placebo and TXA groups in lower GI bleeding 5.

Adverse Events

• Extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes but increased adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 6.
• Low-dose IV/enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 6.