Can Tranexamic Acid (TXA) stop gastrointestinal bleeding?

From the Guidelines

Tranexamic Acid (TXA) is not recommended as a routine treatment to stop gastrointestinal bleeding, particularly in patients with cirrhosis and variceal bleeding, as it has been shown to have no beneficial effect on mortality and may even increase the risk of venous thromboembolic events 1.

Mechanism of Action

TXA is an antifibrinolytic agent that works by inhibiting the breakdown of fibrin clots, which can help stabilize clots that have formed in the gastrointestinal tract and stop bleeding.

Efficacy in GI Bleeding

However, the evidence suggests that TXA may not be effective in stopping gastrointestinal bleeding, especially in cases of variceal bleeding. A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA on mortality, and even reported an increased incidence of venous thromboembolic events in the TXA group 1.

Specific Patient Populations

In patients with cirrhosis and active variceal bleeding, the use of TXA is strongly discouraged due to the lack of benefit and potential harm 1. In cases of non-variceal bleeding, the evidence is limited, and TXA should not be used as a routine treatment 1.

Clinical Guidelines

The European Society of Intensive Care Medicine and the British Society of Gastroenterology recommend against the routine use of TXA in gastrointestinal hemorrhage, citing the lack of clear benefit and potential harms 1. The EASL clinical practice guidelines also discourage the use of TXA in patients with cirrhosis and active variceal bleeding, and recommend a case-by-case approach for patients with non-variceal bleeding 1.

Dosage and Administration

There is no recommended dosage of TXA for the treatment of gastrointestinal bleeding, as its use is not supported by the evidence. However, in cases where TXA is considered, the dosage should be carefully evaluated to minimize the risk of adverse effects.

Adverse Effects

The use of TXA has been associated with an increased risk of venous thromboembolic events, particularly in patients with cirrhosis and variceal bleeding 1. Other potential adverse effects of TXA include seizures and renal impairment.

Alternative Treatments

The management of gastrointestinal bleeding should be tailored to the individual patient, taking into account the underlying cause and severity of the bleed. Alternative treatments, such as endoscopic therapy, portal hypertension-lowering drugs, and blood transfusions, may be more effective in stopping gastrointestinal bleeding and improving patient outcomes 1.

From the FDA Drug Label

Gastrointestinal Bleeding and Tranexamic Acid

The provided FDA Drug Label for tranexamic acid (TXA) does not directly address its effectiveness in stopping gastrointestinal bleeding [ 2 ].

Adverse Effects

However, it does mention that gastrointestinal symptoms such as nausea, vomiting, and diarrhea can occur as a result of overdosage [ 2 ]. The label lists the following potential symptoms of overdosage:

• Gastrointestinal: nausea, vomiting, diarrhea
• Hypotensive: orthostatic symptoms
• Thromboembolic: arterial, venous, embolic
• Neurologic: visual impairment, convulsions, headache, mental status changes
• Myoclonus
• Rash

There is no information in the provided label to suggest that tranexamic acid can stop gastrointestinal bleeding.

From the Research

Efficacy of Tranexamic Acid in Gastrointestinal Bleeding

• The use of tranexamic acid (TXA) in acute gastrointestinal bleeding has been studied in several trials, with varying results 3, 4, 5, 6, 7.
• A 2015 study found that TXA probably decreases rebleeding and mortality in patients with upper gastrointestinal bleeding, without increasing thromboembolic adverse effects 3.
• A 2020 systematic review with meta-analysis found that TXA is superior to placebo for reducing mortality in patients with upper gastrointestinal bleeding, with a risk ratio of 0.59 (95% CI 0.43-0.82, P = 0.001) 7.
• However, a 2024 systematic review and meta-analysis found that TXA does not reduce mortality in patients with acute upper or lower gastrointestinal bleeding and may confer an increased risk of seizures 5.

Safety and Adverse Effects

• The majority of studies found no significant increase in thromboembolic events with the use of TXA 3, 6, 7.
• One trial reported an increased risk of seizure in the TXA group, with a risk ratio of 1.73 (95% CI 1.03-2.93) 5.
• The quality of evidence for the safety and adverse effects of TXA is generally considered moderate due to risk of bias 7.

Clinical Implications

• The use of TXA in gastrointestinal bleeding may be beneficial in reducing mortality, particularly in patients with upper gastrointestinal bleeding 3, 7.
• However, the evidence is not consistent, and further higher-quality trials are needed to confirm the efficacy and safety of TXA in this setting 5, 7.
• Clinicians should carefully consider the potential benefits and risks of TXA in individual patients with gastrointestinal bleeding, taking into account the latest available evidence 3, 4, 5, 6, 7.