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

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed 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. When considering the use of TXA in GI bleeding, it's essential to differentiate between variceal and non-variceal bleeding. In variceal bleeding, which is often associated with cirrhosis and portal hypertension, the evidence suggests that TXA is not effective in stopping the bleed and may even be harmful due to the increased risk of thrombotic events 1. In contrast, the evidence for TXA in non-variceal GI bleeding is more nuanced, with some studies suggesting a potential benefit in reducing mortality, particularly when given early in acute upper GI bleeding 1. However, this benefit is modest and should be weighed against the potential risks of TXA, including thrombotic events. Key points to consider when evaluating the use of TXA in GI bleeding include:

• The underlying cause of the bleeding, with variceal bleeding being a distinct entity that may not benefit from TXA
• The potential risks of TXA, including thrombotic events, which may be increased in patients with cirrhosis and portal hypertension
• The importance of standard treatments, such as proton pump inhibitors, endoscopic interventions, and correction of coagulopathies, which should not be replaced by TXA
• The need for individualized decision-making, taking into account the patient's specific clinical context and risk factors.

From the Research

Effectiveness of TXA in Stopping GI Bleed

• The use of tranexamic acid (TXA) in stopping gastrointestinal (GI) bleeding has been studied in several trials, with varying results 2, 3, 4, 5, 6.
• A systematic review and meta-analysis published in 2021 found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo in patients with upper GI bleeding 2.
• Another study published in 2021 found no significant positive effect of TXA in patients with upper GI bleeding, suggesting that the difference between the two groups may be due to the selection of patients treated with TXA rather than the drug's effect 3.
• A systematic review published in 2008 found that TXA may reduce all-cause mortality in patients with upper GI bleeding, but the evidence was limited by the small number of trials and the risk of bias 4.
• A more recent systematic review and meta-analysis published in 2022 found that extended-use high-dose IV TXA did not improve mortality or bleeding outcomes and increased adverse events, while low-dose IV/enteral TXA may be effective in reducing hemorrhage but requires more evidence to demonstrate its safety 5.
• A Cochrane review published in 2014 found that TXA appears to have a beneficial effect on mortality, but the high dropout rate in some trials means that the results are uncertain, and further research is needed to confirm the findings 6.

Key Findings

• TXA may be effective in reducing continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 2.
• The effectiveness of TXA in stopping GI bleed may depend on the dose and duration of treatment, as well as the patient population 5.
• Further research is needed to confirm the findings and to determine the optimal dose and duration of TXA treatment for GI bleeding 2, 6.

Adverse Events

• TXA may increase the risk of adverse events, such as deep venous thrombosis, pulmonary embolism, and seizure, particularly with extended-use high-dose IV treatment 5.
• The risk of adverse events should be carefully considered when deciding whether to use TXA to treat GI bleeding 5.