From the Guidelines
Tranexamic acid (TXA) may be beneficial in stopping a GI bleed, but its use should be confined to clinical trials or specific cases with mild bleeding, as the current evidence is not strong enough to support its routine use in acute lower gastrointestinal bleeding. The most recent and highest quality study on this topic is from 2021, which recommends TXA for patients with mild GI bleeding due to its low potential for harm, but notes that there is limited evidence of effectiveness 1. In terms of dosing, TXA is typically administered as 1 gram intravenously every 6-8 hours until bleeding stops, or orally at 1-1.5 grams three to four times daily. Some key points to consider when using TXA for GI bleeding include:
- TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites
- TXA should not replace standard treatments like endoscopic intervention, proton pump inhibitors, or vasopressors for variceal bleeding
- Potential side effects include nausea, vomiting, and a theoretical risk of thrombotic events, though this risk is generally low in the acute setting
- TXA should be used with caution in patients with a history of thromboembolic disease or severe renal impairment, with dose adjustments needed for renal dysfunction. It's also worth noting that a previous study from 2019 found that TXA improved mortality from trauma and had some benefit in acute GI bleeding, but the treatment benefit for mortality was no longer apparent when the analysis was limited to trials at low risk of bias 1. Overall, while TXA may be beneficial in certain cases of GI bleeding, its use should be approached with caution and considered on a case-by-case basis, taking into account the patient's individual risk factors and the severity of their bleeding.
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.
Administration and Dosage of TXA
- A double-blind randomized controlled trial compared the efficacy of intravenous TXA with and without topical administration versus placebo in urgent endoscopy rate for acute gastrointestinal bleeding, and found that TXA can aid in changing an urgent endoscopy to an elective procedure, with better outcomes for both physicians and patients 4.
- A systematic review and meta-analysis found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 5.
Safety and Adverse Events of TXA
- A systematic review and meta-analysis 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 increase the risk of adverse events 5.
- A meta-analysis found that TXA was not associated with a significant increase in thrombotic events, but the need for cautious interpretation and individualized patient management is necessary when considering TXA for GI bleeding 3.
Clinical Practice and Utilization of TXA
- A retrospective cohort study found that the overall utilization rate of TXA for upper gastrointestinal bleeding was 0.87%, and the utilization rate did not differ significantly between surgical and medical intensivists 6.
- The study suggests that TXA may be underused in the management of upper gastrointestinal bleeding, and further research is needed to determine the optimal use of TXA in clinical practice 6.