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, especially in cases of variceal bleeding, due to the lack of benefit in mortality outcomes and potential increased risk of thromboembolic events. TXA works by inhibiting the breakdown of blood clots, which can reduce bleeding severity and duration in some cases. However, for acute upper GI bleeding, the primary treatments remain endoscopic intervention, proton pump inhibitors (like pantoprazole 40mg IV twice daily), and correction of coagulopathies 1.

Key Points to Consider

• TXA appears most beneficial in patients with bleeding related to mucosal lesions rather than variceal bleeding.
• While TXA can reduce rebleeding rates and transfusion requirements in some studies, it doesn't consistently improve mortality outcomes in GI bleeding 1.
• The medication should be used cautiously in patients with thromboembolic risk factors, as it may potentially increase clotting risks.
• A large randomised placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of tranexamic acid in the whole group nor in the subgroup analysis of patients with suspected variceal bleeding and liver disease comorbidity 1.
• The use of TXA in GI bleeding should be considered as part of a comprehensive approach that includes identifying and treating the underlying cause of bleeding.

Clinical Considerations

• In patients with cirrhosis and active variceal bleeding, TXA should not be used due to the lack of benefit and potential increased risk of thromboembolic events 1.
• In patients with cirrhosis and active bleeding related to portal hypertension, but not to varices, the use of TXA is not indicated to stop bleeding.
• A restrictive red blood cell transfusion strategy is beneficial in patients with cirrhosis and active bleeding, as administration of large volumes of blood products may paradoxically increase bleeding rather than contribute to control of bleeding 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.