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 has no beneficial effect in this context and may even increase the risk of thromboembolic events. The use of TXA in GI bleeding has been evaluated in several studies, including a large randomized placebo-controlled trial of 12,009 patients with acute upper gastrointestinal bleeding, which found no beneficial effect of TXA in reducing mortality due to bleeding 1. In fact, the study found an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group.
The primary management of GI bleeding should focus on identifying and treating the underlying cause, such as endoscopic intervention for bleeding ulcers or varices. TXA may be considered as an adjunctive therapy in certain cases, but its use should be cautious and carefully weighed against the potential risks, particularly in patients with thromboembolic risk factors. The medication works by inhibiting plasminogen activation, which prevents the dissolution of fibrin clots that form at bleeding sites. However, the limited role of hemostasis in variceal bleeding and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis may explain why TXA is ineffective in this context 1.
Some key points to consider when managing GI bleeding include:
- Identifying and treating the underlying cause of the bleed
- Using endoscopic intervention for bleeding ulcers or varices
- Considering the use of TXA as an adjunctive therapy in certain cases, but with caution and careful consideration of the potential risks
- Being aware of the potential for TXA to increase the risk of thromboembolic events, particularly in patients with comorbid liver disease or suspected variceal bleeding 1.
It is also important to note that the use of blood products, such as transfusions, may actually increase portal pressure and worsen outcomes in patients with cirrhosis and GI bleeding 1. Therefore, a restrictive transfusion strategy may be beneficial in these patients. Overall, the management of GI bleeding should be individualized and based on the specific underlying cause and patient factors, with careful consideration of the potential benefits and risks of different treatment options, including TXA 1.
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.