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, as the most recent and highest quality evidence suggests it does not provide a significant benefit in reducing mortality or rebleeding rates, and may even increase the risk of thromboembolic events. 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 reducing death due to bleeding within the first 5 days. Furthermore, the study reported an almost 2-fold increase in the incidence of venous thromboembolic events in the tranexamic acid group compared to the placebo group.

The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting potential benefits in certain scenarios, such as upper GI bleeding due to peptic ulcer disease or gastritis. However, the most recent and highest quality evidence, as reported in the study published in the Journal of Hepatology in 2022 1, suggests that TXA should not be used in patients with cirrhosis and active variceal bleeding, and its use in other types of GI bleeding should be approached with caution.

Some key points to consider when evaluating the use of TXA in GI bleeding include:

• The risk of thromboembolic complications, particularly in patients with pre-existing cardiovascular disease or thrombotic tendencies
• The potential for TXA to increase portal pressure, which may worsen outcomes in patients with portal hypertensive bleeding
• The importance of individual risk assessment and comprehensive management approaches that may include endoscopic therapy, proton pump inhibitors, and other interventions as appropriate

In terms of specific dosing and administration, the study published in Gut in 2019 1 suggests that TXA is typically administered as 1 gram intravenously every 6-8 hours for 24-48 hours, or until bleeding is controlled. However, given the lack of evidence supporting the use of TXA in GI bleeding, it is not recommended to use this medication for this indication.

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.