From the Guidelines
Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, as the most recent and highest quality evidence does not support its effectiveness in this context. 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 stopping the bleed, and even reported an increased incidence of venous thromboembolic events in the tranexamic acid group.
The primary treatments for GI bleeding typically include:
- Endoscopic interventions
- Proton pump inhibitors (like pantoprazole 40mg IV twice daily)
- Addressing the underlying cause TXA may be considered in specific scenarios such as bleeding associated with coagulopathies or when endoscopic treatment is delayed or unavailable, but its use should be guided by the specific cause and severity of the bleeding. The medication works by inhibiting plasminogen activation, preventing the dissolution of formed clots.
It's also important to note that the British Society of Gastroenterology guidelines published in 2019 1 suggest that the use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial. However, the more recent study from 2022 1 provides higher quality evidence that supersedes these guidelines.
In patients with cirrhosis and active variceal bleeding, the use of tranexamic acid is not recommended due to the lack of benefit and potential increased risk of thromboembolic events 1. The management of variceal bleeding should focus on prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, rather than the use of antifibrinolytic agents like tranexamic acid.
In summary, the use of tranexamic acid to stop a GI bleed is not supported by the most recent and highest quality evidence, and its use should be approached with caution and considered on a case-by-case basis.
From the Research
Effectiveness of Tranexamic Acid in GI Bleeding
- Tranexamic acid (TXA) has been shown to be effective in reducing bleeding in patients with upper gastrointestinal bleeding, with a significant reduction in continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 2.
- A double-blind randomized controlled trial found that early intravenous and/or intravenous plus topical administration of TXA reduced the need for urgent endoscopy for acute gastrointestinal bleeding 3.
- The HALT-IT trial, an international, randomized, double-blind, placebo-controlled 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.
Limitations and Variability in Effectiveness
- The effectiveness of TXA in lower gastrointestinal bleeding is less clear, with one study finding no significant effect on blood transfusion requirements in patients with lower GI bleeding 5.
- 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 due to limitations in the internal and external validity of included trials 6.
- The variability in study findings highlights the need for further research to fully understand the effectiveness of TXA in GI bleeding, particularly in different patient populations and bleeding locations.
Key Findings and Implications
- TXA has been shown to be effective in reducing bleeding and improving outcomes in patients with upper gastrointestinal bleeding, but its effectiveness in lower GI bleeding is uncertain.
- Early administration of TXA may be beneficial in treating upper gastrointestinal bleeding in the emergency department, but further clarification is needed on its effects in lower GI bleeding.
- The results of ongoing and future studies, such as the HALT-IT trial, will provide valuable insights into the effectiveness and safety of TXA in GI bleeding, informing treatment recommendations and guidelines 2, 3, 4, 5, 6.