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. 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 mortality due to bleeding, and instead observed an increased incidence of venous thromboembolic events in the tranexamic acid group.
The mechanism of action of TXA involves inhibiting plasminogen activation and preventing fibrin clot breakdown, which can be beneficial in certain types of bleeding. However, in the context of GI bleeding, the evidence suggests that TXA is not effective and may even be harmful. The study published in Gut in 2019 1 also notes that the use of tranexamic acid in acute lower GI bleeding is not recommended outside of clinical trials, pending the results of the HALT-IT trial.
Some key points to consider when managing GI bleeding include:
- The importance of prompt initiation of standard therapies such as vasoactive therapy, antibiotics, and endoscopic treatment
- The potential risks of thrombotic complications associated with the use of tranexamic acid, particularly in patients with comorbid liver disease or suspected variceal bleeding
- The need for a restrictive red blood cell transfusion strategy to avoid increasing portal pressure and worsening outcomes
- The importance of individualized management of patients with cirrhosis and active bleeding, taking into account the underlying cause of the bleeding and the patient's overall clinical condition.
In terms of specific treatment approaches, the evidence suggests that:
- Tranexamic acid should not be used as a first-line treatment for GI bleeding
- Standard therapies such as proton pump inhibitors, endoscopic interventions, and blood product replacement should be used as the primary treatment approach
- Tranexamic acid may be considered as an adjunctive therapy in certain cases, but its use should be carefully weighed against the potential risks and benefits.