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 patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect and may even increase the risk of venous thromboembolic events 1. The use of TXA in GI bleeding is a topic of ongoing debate, with some studies suggesting potential benefits in certain scenarios. However, the most recent and highest quality evidence suggests that TXA is not effective in stopping GI bleeds, particularly in patients with cirrhosis and variceal bleeding.

• The EASL clinical practice guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis strongly recommend against the use of TXA in patients with cirrhosis and active variceal bleeding, citing a lack of benefit and potential harm 1.
• A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA in reducing mortality or re-bleeding rates, and actually observed an increased risk of venous thromboembolic events in the TXA group 1.
• The British Society of Gastroenterology guidelines on diagnosis and management of acute lower gastrointestinal bleeding suggest that TXA may have some benefit in acute GI bleeding, but note that the evidence is limited and that its use should be confined to clinical trials pending further results 1. Key points to consider when evaluating the use of TXA in GI bleeding include:
• The underlying cause of the bleed, with variceal bleeding being a specific scenario where TXA has been shown to be ineffective
• The potential risks of TXA, including venous thromboembolic events
• The importance of using TXA as an adjunct to standard treatments, rather than as a standalone therapy Overall, the current evidence suggests that TXA should not be used as a first-line treatment for GI bleeding, particularly in patients with cirrhosis and variceal bleeding.

From the Research

Effectiveness of Tranexamic Acid in Gastrointestinal Bleeding

• Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with some studies suggesting it may be effective in reducing bleeding and mortality 2, 3, 4.
• A systematic review and meta-analysis of randomized controlled trials found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 2.
• Another study found that early administration of TXA was associated with a reduced risk of mortality in patients with GI bleeding, without an increase in thromboembolic events 4.
• However, other studies have found that the effects of TXA on GI bleeding are limited or highly heterogeneous, and that additional evidence is needed to determine its effectiveness 3, 5, 6.

Dosage and Administration

• The optimal dosage and administration of TXA for GI bleeding are unclear, with some studies suggesting that high-dose IV TXA may not be effective in reducing mortality or bleeding outcomes 5.
• Low-dose IV or enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 5.
• Early administration of TXA may be beneficial in reducing mortality, but the timing of administration is not well established 4.

Safety and Adverse Events

• TXA has been associated with an increased risk of thromboembolic events, such as deep venous thrombosis and pulmonary embolism 5.
• However, other studies have found that TXA does not significantly increase the risk of thromboembolic events 3, 4, 6.
• The safety and adverse event profile of TXA in patients with GI bleeding require further study.