Can tranexamic acid (TXA) stop gastrointestinal (GI) bleeding?

From the Guidelines

Tranexamic acid (TXA) is not recommended as a standard treatment to stop gastrointestinal (GI) bleeding, as the current evidence does not support its effectiveness in this context.

Mechanism of Action and Evidence

• TXA is an antifibrinolytic agent that inhibits the breakdown of fibrin clots, which are crucial for stopping bleeding 1.
• The evidence from studies on the use of TXA in GI bleeding is mixed and often limited by small sample sizes and variability in patient populations 1.
• A large randomized placebo-controlled trial of 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA on mortality due to bleeding, and an increased risk of venous thromboembolic events 1.

Clinical Guidelines and Recommendations

• The British Society of Gastroenterology suggests that the use of TXA in acute lower GI bleeding be confined to clinical trials, pending the results of further studies 1.
• The European Association for the Study of the Liver (EASL) recommends against the use of TXA in patients with cirrhosis and active variceal bleeding, due to the lack of evidence for its effectiveness and potential risks of thromboembolic events 1.
• The European Society of Intensive Care Medicine guidelines state that there is high certainty of harms with the use of high-dose IV TXA and no clear benefit with its general use in gastrointestinal hemorrhage 1.

Specific Patient Populations

• In patients with cirrhosis and active bleeding related to portal hypertension, correction of coagulopathy with blood products or other agents may be considered on a case-by-case basis, but TXA is not recommended 1.
• In patients with cirrhosis and bleeding from non-portal hypertensive causes, such as gastric vascular ectasia, TXA may be considered in refractory cases, but its use is not well established 1.

From the FDA Drug Label

Tranexamic acid (TXA) is not indicated to stop gastrointestinal (GI) bleeding.

• The drug label for tranexamic acid injection 2 indicates that it is used to reduce or prevent hemorrhage in patients with hemophilia during and following tooth extraction, but does not mention GI bleeding as an indication.
• The label also lists the most common adverse reactions, which include gastrointestinal symptoms such as nausea, vomiting, and diarrhea, but does not suggest that the drug is used to treat these conditions 2.
• Another drug label for tranexamic acid 2 describes the symptoms of overdosage, which may include gastrointestinal symptoms, but again does not indicate that the drug is used to stop GI bleeding.
• A third drug label for tranexamic acid 2 repeats the indication for use in patients with hemophilia to reduce or prevent hemorrhage during and following tooth extraction, without mentioning GI bleeding.

From the Research

Effectiveness of Tranexamic Acid in GI Bleeding

• Tranexamic acid (TXA) has been shown to be effective in reducing mortality and bleeding in patients with upper gastrointestinal bleeding 3, 4, 5.
• 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 3.
• Another study found that early administration of TXA was associated with a reduced risk of mortality in patients with gastrointestinal bleeding, without an increase in thromboembolic events 4.

Upper vs. Lower GI Bleeding

• The effectiveness of TXA in lower gastrointestinal bleeding is less clear, with one study finding no significant effect on blood transfusion requirements 6.
• In contrast, TXA has been shown to be effective in reducing bleeding and mortality in upper gastrointestinal bleeding 3, 4, 5.

Timing of TXA Administration

• Early administration of TXA may be beneficial in reducing mortality and bleeding in patients with gastrointestinal bleeding 4.
• A study found that early TXA treatment was associated with a reduced risk of mortality compared to late treatment, without an increase in thromboembolic events 4.

Safety and Adverse Events

• The safety profile of TXA in GI bleeding is generally considered to be good, with no significant increase in thromboembolic events reported in several studies 3, 4, 5.
• However, adverse events were not always clearly reported in the included trials, and further research is needed to fully assess the safety of TXA in this context 5.