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, particularly in cases of variceal bleeding, due to the lack of beneficial effect and potential increased risk of venous thromboembolic events. The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in reducing mortality in acute upper GI bleeding 1. However, a more recent and higher-quality study found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 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.

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

• The mechanism of action of TXA, which involves inhibiting plasminogen activation and preventing the dissolution of fibrin clots that form at bleeding sites
• The potential benefits of TXA in reducing bleeding in certain cases, such as mucosal bleeding
• The lack of beneficial effect of TXA in variceal bleeding, and the potential increased risk of venous thromboembolic events
• The importance of comprehensive care for patients with GI bleeding, including fluid resuscitation, blood product replacement as needed, and definitive treatment of the underlying cause of bleeding

In terms of specific treatment recommendations, the guidelines suggest that TXA should not be used in patients with cirrhosis and active variceal bleeding 1. Instead, treatment should focus on standard therapies such as endoscopic intervention, proton pump inhibitors, and correction of coagulopathy. In cases of non-variceal bleeding, the use of TXA may be considered on a case-by-case basis, but the potential benefits and risks should be carefully weighed. Overall, the use of TXA in GI bleeding should be approached with caution, and treatment decisions should be based on the individual patient's needs and circumstances.

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.