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, as it has been shown to have no beneficial effect and may even increase the risk of venous thromboembolic events 1.
Background and Rationale
The use of TXA in GI bleeding has been evaluated in various studies, with a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding showing no beneficial effect of TXA in reducing mortality due to bleeding within the first 5 days 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, particularly in patients with comorbid liver disease or suspected variceal bleeding.
Clinical Considerations
In patients with cirrhosis and active variceal bleeding, the primary goal is to achieve haemostasis using portal hypertension-lowering drugs and endoscopic treatment, rather than correcting haemostatic abnormalities with TXA or other medications 1. The use of TXA in this context may even be harmful, as it can increase the risk of thrombotic complications. Instead, a restrictive red blood cell transfusion strategy is recommended, as administration of large volumes of blood products may paradoxically increase bleeding rather than contribute to control of bleeding.
Key Takeaways
- TXA should not be used to stop a GI bleed in patients with cirrhosis and active variceal bleeding due to lack of efficacy and increased risk of thrombotic complications 1.
- The primary goal in managing variceal bleeding is to achieve haemostasis using portal hypertension-lowering drugs and endoscopic treatment, rather than correcting haemostatic abnormalities with TXA or other medications.
- A restrictive red blood cell transfusion strategy is recommended to minimize the risk of worsening bleeding and thrombotic complications.
From the Research
Effectiveness of Tranexamic Acid in Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been shown to be effective in reducing hemorrhage in patients with upper gastrointestinal bleeding 2.
- A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- However, the effects of TXA on lower gastrointestinal bleeding are less clear, with one study finding no significant effect on blood transfusion requirements 3.
- Another study found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but increased adverse events such as deep venous thrombosis, pulmonary embolism, and seizure 4.
- Low-dose IV/enteral TXA may be effective in reducing hemorrhage, but more evidence is required to demonstrate its safety 4.
Timing of Tranexamic Acid Administration
- Early administration of TXA has been associated with a reduced risk of mortality in patients with gastrointestinal bleeding, without an increase in thromboembolic events 5.
- A population-based cohort study found that early TXA treatment was associated with a significant decrease in cumulative incidence of mortality, compared to late treatment 5.
Clinical Trials and Economic Analysis
- A large randomized controlled trial found that TXA did not reduce death from gastrointestinal bleeding, and was not cost-effective in adults with acute gastrointestinal bleeding 6.
- The trial found that TXA was associated with a higher risk of venous thromboembolic events, but not arterial thromboembolic events 6.
- The results of this trial caution against a uniform approach to the management of patients with major haemorrhage, and highlight the need for randomized trials targeted at specific pathophysiological processes 6.