From the Guidelines
Tranexamic acid (TXA) should not be used as a first-line treatment for gastrointestinal (GI) bleeding outside of clinical trials, due to limited and uncertain evidence of its benefit in this context. For patients with GI bleeding, primary management should focus on resuscitation, proton pump inhibitors for upper GI bleeds, and endoscopic intervention to directly treat the bleeding source. TXA may be considered as an adjunctive therapy in certain cases, such as when endoscopy is delayed or unavailable, but its use should be weighed against the potential risks of thrombotic complications 1.
Mechanism and Potential Benefits
TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites, making it potentially useful for mucosal bleeding. However, the evidence for its benefit in acute GI bleeding is limited and uncertain, with some studies suggesting a potential reduction in mortality, but this benefit was not apparent in trials with low risk of bias 1.
Current Recommendations and Guidelines
The British Society of Gastroenterology 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 1. In contrast, guidelines for hereditary hemorrhagic telangiectasia recommend TXA for patients with mild GI bleeding, but note that there is limited evidence of effectiveness 1.
Clinical Considerations
In clinical practice, the decision to use TXA in GI bleeding should be made on a case-by-case basis, taking into account the potential benefits and risks, as well as the availability of other treatment options. It is essential to prioritize resuscitation, proton pump inhibitors, and endoscopic intervention as the primary management strategies for GI bleeding, and to consider TXA as an adjunctive therapy only when necessary.
From the Research
Efficacy of Tranexamic Acid in Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with some studies suggesting its effectiveness in reducing bleeding and mortality rates 2, 3.
- A double-blind randomized controlled trial published in 2018 found that TXA reduced the need for urgent endoscopy in patients with acute GI bleeding, although it did not significantly affect mortality, re-bleeding, or blood transfusion rates 2.
- A systematic review and meta-analysis published in 2021 found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 3.
- Another systematic review and meta-analysis published in 2022 found that extended-use high-dose IV TXA did not improve mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 4.
Timing of Tranexamic Acid Administration
- A population-based cohort study published in 2022 found that early TXA administration was associated with a reduced risk of mortality in patients with GI bleeding, without an increase in thromboembolic events 5.
- The study suggested that early TXA treatment may be beneficial in reducing mortality rates, although further randomized clinical trials are needed to confirm these findings 5.
Safety and Adverse Events
- The use of TXA in GI bleeding has been associated with an increased risk of thromboembolic events, such as deep venous thrombosis and pulmonary embolism 4.
- However, other studies have found no significant association between TXA treatment and thromboembolic events 5.
- The safety and efficacy of TXA in GI bleeding require further study, particularly in terms of optimal dosing and timing of administration 6.