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 the breakdown of blood clots, which helps control bleeding. 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, if TXA were to be used, it would typically be administered as 1 gram intravenously every 6-8 hours for 24-48 hours, or until bleeding is controlled. However, given the lack of evidence supporting its use, TXA should not be considered a first-line therapy for GI bleeds. Instead, standard treatments like endoscopic intervention, proton pump inhibitors, and correction of coagulopathies should be prioritized. Patients with GI bleeding should be managed on a case-by-case basis, taking into account the underlying cause of the bleed, the presence of comorbidities, and the risk of thrombotic events.
Some key points to consider when managing GI bleeding include:
- The importance of prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment
- The need for careful monitoring of patients for potential side effects, including thrombotic events
- The limited role of haemostasis in variceal bleeding and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis
- The potential risks and benefits of correcting haemostatic abnormalities in patients with cirrhosis and active variceal bleeding.
From the Research
Effectiveness of Tranexamic Acid in GI Bleeding
- Tranexamic acid (TXA) has been shown to reduce the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A double-blind randomized controlled trial found that early intravenous and/or intravenous plus topical administration of TXA reduces the need for urgent endoscopy for acute gastrointestinal bleeding 3.
- The HALT-IT 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.
Upper GI Bleeding
- 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 before treatment recommendations can be made due to limitations in the internal and external validity of included trials 5.
- Another study found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
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 packed red blood cells units among the patients in the placebo and TXA groups 6.
- The HALT-IT trial also aims to investigate the effects of TXA on lower GI bleeding, but the results are not yet available 4.