From the Guidelines
Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, as the most recent and highest quality study found no beneficial effect of TXA in acute upper gastrointestinal bleeding, and even suggested a potential increase in venous thromboembolic events 1. The use of TXA in GI bleeding has been evaluated in several studies, with mixed results. However, the most recent and highest quality study, published in 2022, found that TXA did not reduce mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, and was associated with an increased risk of venous thromboembolic events 1. Some key points to consider when evaluating the use of TXA in GI bleeding include:
- The mechanism of action of TXA, which involves inhibiting fibrinolysis and stabilizing blood clots 1
- The potential benefits of TXA in certain types of bleeding, such as trauma-induced bleeding 1
- The lack of evidence supporting the use of TXA in GI bleeding, particularly in patients with cirrhosis and variceal bleeding 1
- The potential risks of TXA, including venous thromboembolic events and other adverse effects 1 In clinical practice, the decision to use TXA in GI bleeding should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of treatment. However, based on the current evidence, TXA should not be used as a first-line treatment for GI bleeding, and other standard treatments such as endoscopic intervention and correction of coagulopathies should be prioritized 1.
From the Research
Effectiveness of Tranexamic Acid in GI 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 systematic review and meta-analysis of randomized clinical trials found that TXA significantly reduced the rates of continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with the placebo 2.
- Another study found that early administration of TXA may be worth recommending for treating upper gastrointestinal bleeding in the emergency department 2.
Timing of TXA Administration
- A population-based cohort study found that early TXA administration reduced the risk of mortality in patients with gastrointestinal bleeding, with a significant decrease in cumulative incidence of mortality in the early TXA treatment group (log-rank test: p < 0.0001) 3.
- The study also found that multiple Cox regression analysis revealed significantly lower mortality in the early TXA treatment group compared with the late treatment group (aHR: 0.64,95% CI: 0.57−0.73) 3.
TXA in Lower GI Bleeding
- A double-blind prospective randomized controlled trial found that intravenous TXA has no significant effect on blood requirement in patients with lower GI bleeding, with no difference in the consumption of PRBC units among the patients in the placebo and TXA groups 4.
- The study found that 43 out of the 81 patients received blood transfusion, with 22 in the placebo arm and 21 in the TXA arm (p = 0.89), and 29 patients required 2 or more units, 14 in the TXA arm and 15 in the placebo arm (p = 0.98) 4.
Safety and Efficacy
- A study found that TXA seems appropriate as adjuvant treatment during upper gastrointestinal bleeding, but patients are often old and have several co-morbidities, and therefore, thromboembolic risk and TXA dosage should be carefully evaluated 5.
- Another study found that no thromboembolic event was documented during the 1-week follow up, and no significant statistical differences were seen between treatment groups regarding mortality, re-bleeding, blood transfusion, and endoscopic and/or surgical intervention rates 6.