Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed, as the most recent and highest quality study suggests it has no beneficial effect in variceal bleeding and may even increase the risk of venous thromboembolic events 1.

Key Points to Consider

• The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in certain cases, but the most recent evidence does not support its use as a first-line treatment.
• The primary approaches to managing GI bleeds include endoscopic intervention, proton pump inhibitors for upper GI bleeds, and addressing the underlying cause.
• TXA may be considered as an adjunctive therapy in specific cases, but its use should be carefully weighed against the potential risks, including thrombotic events.
• The most recent study on the topic, published in 2022, found that TXA had no beneficial effect in variceal bleeding and may even increase the risk of venous thromboembolic events 1.

Potential Side Effects and Risks

• Nausea, vomiting, diarrhea
• Theoretical risk of thrombotic events, though this risk appears low in most patients without specific risk factors for thrombosis
• Increased risk of venous thromboembolic events, particularly in patients with comorbid liver disease/suspected variceal bleeding

Clinical Decision-Making

• The decision to use TXA in GI bleeding should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of treatment.
• Clinicians should carefully consider the most recent evidence and guidelines when making decisions about the use of TXA in GI bleeding.
• The primary goal of treatment should always be to prioritize the patient's morbidity, mortality, and quality of life, and to use the most effective and safest treatments available.

From the Research

Efficacy of Tranexamic Acid (TXA) in Stopping GI Bleed

• TXA has been shown to be effective in reducing the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
• A systematic review and meta-analysis found that TXA significantly reduced rebleeding rates overall, and this effect was more pronounced in studies with a lower risk of bias 3.
• TXA use was associated with a mortality reduction when administered through both oral and intravenous routes, and in cases of upper GI bleeding 3.

Reduction in Urgent Endoscopy and Mortality

• A double-blind randomized controlled trial found that the need for urgent endoscopy was significantly lower in patients treated with TXA compared to those receiving a placebo 4.
• A systematic review and meta-analysis found that TXA reduced mortality in patients with upper GI bleeding, but increased mortality in patients with lower GI bleeding 3.

Adverse Events and Safety

• A systematic review and meta-analysis found that TXA was linked to a significant increase in mortality in patients with lower GI bleeding, but there was no definitive evidence that its use is associated with thromboembolic events 3.
• Another study found that extended-use high-dose IV TXA resulted in a small increase in deep venous thrombosis, pulmonary embolism, and seizure, but low-dose IV/enteral TXA did not reduce mortality but did reduce the risk of rebleeding and need for surgery 5.

Clinical Implications

• The use of TXA in patients with GI bleeding may be beneficial in reducing rebleeding and mortality, particularly in those with upper GI bleeding 2, 3.
• However, the effects of TXA on lower GI bleeding warrant further clarification, and its use should be approached with caution and individualized patient management 2, 3.