From the Guidelines
Tranexamic acid (TXA) should not be used to stop an upper gastrointestinal bleed, especially in patients with cirrhosis and variceal bleeding, as it has been shown to have no beneficial effect and may even increase the risk of venous thromboembolic events 1.
Key Points
- A large randomized placebo-controlled trial of 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of tranexamic acid in reducing mortality due to bleeding, and actually found an increased risk of venous thromboembolic events 1.
- The use of tranexamic acid is not recommended in patients with cirrhosis and active variceal bleeding, with a strong recommendation against its use (LoE 2) 1.
- The evidence for the use of tranexamic acid in acute GI bleeding is not strong, with some studies showing a benefit in mortality, but this benefit is not apparent when limited to trials at low risk of bias 1.
- The routine use of high-dose acid suppression and endoscopic therapy in modern day care may also limit the extrapolation of older studies on tranexamic acid to current practice 1.
Clinical Considerations
- Standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, with a focus on correcting the underlying cause of the bleeding rather than just the coagulopathy 1.
- The use of blood products, such as platelets and fresh frozen plasma, should be considered on a case-by-case basis, as they may actually increase portal pressure and worsen outcomes 1.
From the FDA Drug Label
Tranexamic Acid (TXA) and Upper Gastrointestinal Bleed
- The FDA drug label for tranexamic acid (TXA) does not directly address its use for stopping an upper gastrointestinal bleed [ 2 ]. The FDA drug label does not answer the question.
From the Research
Effectiveness of Tranexamic Acid in Upper Gastrointestinal Bleeding
- Tranexamic acid (TXA) has been studied for its potential to stop upper gastrointestinal bleeding, with evidence suggesting it may be effective in reducing bleeding and mortality rates 3, 4, 5, 6.
- 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 TXA probably decreases rebleeding and mortality without increasing thromboembolic adverse effects in patients with upper gastrointestinal bleeding 4.
Mechanism of Action and Safety
- TXA works by inhibiting the breakdown of fibrin clots by plasmin, which helps to reduce bleeding 7.
- The safety of TXA in patients with upper gastrointestinal bleeding has been evaluated, with some studies suggesting that it does not significantly increase the risk of thromboembolic disease 5, 6.
Clinical Trials and Recommendations
- The HALT-IT trial, a large international randomized controlled trial, aimed to provide reliable evidence about the effects of TXA in acute upper and lower GI bleeding 7.
- While some studies suggest that TXA may be effective in reducing bleeding and mortality, others have noted limitations in the internal and external validity of included trials, highlighting the need for additional evidence before treatment recommendations can be made 5, 6.