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

From the Guidelines

Tranexamic acid (TXA) should not be used as a standard treatment to stop gastrointestinal (GI) bleeding outside of clinical trials, due to limited and uncertain evidence of its benefit in this context. When considering the use of TXA in GI bleeding, it's essential to weigh the potential benefits against the risks, particularly the risk of thromboembolic events. According to the British Society of Gastroenterology guidelines 1, while there is some evidence suggesting that TXA may reduce mortality in acute GI bleeding, this benefit is not consistently supported across all studies, especially when considering only trials with low risk of bias. The guidelines suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of further studies like the HALT-IT trial 1. Key points to consider when evaluating the use of TXA in GI bleeding include:

• The mechanism of action, which involves inhibiting fibrinolysis to stabilize blood clots
• The potential risks, including thrombotic complications, particularly in patients with a history of thromboembolism
• The need for careful patient selection and dose adjustment, especially in patients with renal impairment
• The importance of awaiting results from ongoing clinical trials to inform evidence-based practice.

From the Research

Efficacy of Tranexamic Acid in Gastrointestinal Bleeding

• Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with some studies suggesting its effectiveness in reducing bleeding and improving outcomes 2, 3, 4.
• A double-blind randomized controlled trial published in 2018 found that TXA reduced the need for urgent endoscopy in patients with acute GI bleeding, with a significant difference in the time to endoscopy between the treatment and placebo groups 2.
• A systematic review and meta-analysis published in 2021 found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 3.
• Another systematic review and meta-analysis published in 2022 found that low-dose IV/enteral TXA may be effective in reducing rebleeding and the need for surgery, but extended-use high-dose IV TXA does not improve mortality or bleeding outcomes and increases adverse events 5.

Mechanism of Action and Safety

• TXA works by inhibiting the breakdown of fibrin clots by plasmin, which can help to reduce bleeding in patients with GI bleeding 6.
• The safety of TXA in patients with GI bleeding has been evaluated in several studies, with some finding no significant increase in thromboembolic events 2, 4.
• However, the 2022 systematic review and meta-analysis found that extended-use high-dose IV TXA resulted in a small increase in deep venous thrombosis, pulmonary embolism, and seizure 5.

Clinical Implications

• The use of TXA in patients with GI bleeding may be beneficial in reducing bleeding and improving outcomes, particularly in those with upper GI bleeding 3.
• However, the optimal dosing strategy and safety profile of TXA in this patient population require further study 5.
• The results of the HALT-IT trial, a large international randomized controlled trial evaluating the effects of TXA in acute upper and lower GI bleeding, will provide important information on the efficacy and safety of TXA in this setting 6.