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 improving outcomes in patients with GI bleeding. 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 mechanism of action of TXA involves inhibiting plasminogen activation, which prevents the breakdown of blood clots and helps maintain clot stability. However, in the context of GI bleeding, the limited role of haemostasis and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis may explain why TXA is ineffective. The study published in Gut in 2019 1 also suggests that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial.

In terms of administration, TXA is typically given as 1g IV every 6-8 hours until bleeding stops, or as a continuous infusion of 25mg/kg/day. However, given the lack of evidence supporting its use in GI bleeding, it is not recommended as a first-line treatment. Instead, other treatments like proton pump inhibitors, endoscopic therapy, or vasopressors may be more effective in managing GI bleeding. Potential side effects of TXA include nausea, vomiting, and a theoretical risk of thrombotic events, which appears to be low in the acute setting but may be increased in patients with comorbid liver disease or suspected variceal bleeding.

Key points to consider when managing GI bleeding include:

• The cause and location of bleeding, with upper GI bleeds potentially responding better to treatment than lower GI bleeds
• The use of comprehensive approaches, including proton pump inhibitors, endoscopic therapy, or vasopressors
• The potential risks and benefits of blood product transfusions, which may increase portal pressure and worsen outcomes
• The importance of individualized treatment decisions, taking into account the patient's underlying condition and comorbidities.

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.