From the Guidelines
Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, particularly in patients with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and potential increased risk of venous thromboembolic events. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or rebleeding rates in patients with acute upper gastrointestinal bleeding, and actually increased the risk of venous thromboembolic events. This study included a large randomized controlled trial of 12,009 patients, which provides strong evidence against the use of TXA in this context.
Some key points to consider when managing GI bleeding include:
- Identifying and treating the underlying cause of the bleed, such as endoscopic intervention for ulcers or varices
- Using acid suppression therapy for upper GI bleeds
- Considering the use of other therapies, such as vasoactive agents or blood products, on a case-by-case basis
- Avoiding the use of TXA, particularly in patients with cirrhosis and active variceal bleeding, due to the potential risks and lack of benefit.
It's also important to note that the British Society of Gastroenterology guidelines, published in 2019 in the journal Gut 1, suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of further studies. However, the more recent study published in 2022 1 provides stronger evidence against the use of TXA in GI bleeding, and should be prioritized in clinical decision-making.
From the Research
Effectiveness of Tranexamic Acid in Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been shown to be effective in reducing bleeding in patients with upper gastrointestinal bleeding 2, 3.
- A systematic review and meta-analysis of randomized clinical trials found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 2.
- A double-blind randomized controlled trial found that early administration of TXA reduced the need for urgent endoscopy and improved outcomes in patients with acute gastrointestinal bleeding 3.
Timing of Tranexamic Acid Administration
- A population-based cohort study found that early TXA administration was associated with a reduced risk of mortality in patients with gastrointestinal bleeding, without an increase in thromboembolic events 4.
- The study suggested that early TXA treatment may be beneficial in reducing mortality, but further randomized clinical trials are needed to confirm this finding.
Effectiveness of Tranexamic Acid in Lower Gastrointestinal Bleeding
- A double-blind prospective randomized controlled trial found that intravenous TXA had no significant effect on blood transfusion requirements in patients with lower gastrointestinal bleeding 5.
- The study suggested that TXA may not be effective in reducing bleeding in lower gastrointestinal bleeding, but further studies are needed to confirm this finding.
Overall Evidence
- The current evidence suggests that TXA is effective in reducing bleeding in patients with upper gastrointestinal bleeding, but its effectiveness in lower gastrointestinal bleeding is uncertain 2, 3, 5.
- Further studies are needed to confirm the effectiveness of TXA in gastrointestinal bleeding and to determine the optimal timing of administration 6, 4.