From the Guidelines
Tranexamic acid (TXA) may be beneficial in stopping a GI bleed, particularly in upper GI bleeds, but its use should be approached with caution and considered on a case-by-case basis, especially in lower GI bleeds or in patients with thromboembolic risk factors.
Mechanism and Administration
TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites, making it particularly useful for mucosal bleeding where clot dissolution is a concern 1. For acute management, an initial loading dose of 1-2g may be given, followed by 1g IV every 6-8 hours until bleeding stops, or as a continuous infusion of 25mg/kg over 24 hours.
Efficacy and Safety
While there is some evidence for the benefit of TXA in acute GI bleeding, with a 40% risk reduction in mortality in pooled analysis of several trials 1, this treatment benefit was no longer apparent when the analysis was limited to trials at low risk of bias. Furthermore, the studies were considered historic and before the routine use of high-dose acid suppression and endoscopic therapy, and thus their extrapolation to modern day care is uncertain 1.
Clinical Considerations
TXA appears most beneficial in upper GI bleeds rather than lower GI bleeds 1, and should be used with caution in patients with thromboembolic risk factors since it may potentially increase clotting risk elsewhere in the body. The primary management of GI bleeds should still include addressing the underlying cause through endoscopic intervention, acid suppression with proton pump inhibitors, and hemodynamic support as needed. In cases of hereditary hemorrhagic telangiectasia (HHT), TXA may be recommended for patients with mild GI bleeding due to its low potential for harm, although evidence of effectiveness is limited 1.
From the Research
Efficacy of Tranexamic Acid in GI Bleeding
- Tranexamic acid (TXA) has been studied as a potential treatment for acute gastrointestinal (GI) bleeding, with evidence suggesting its effectiveness in reducing rebleeding rates and mortality in certain cases 2, 3, 4, 5.
- A systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 3.
- Another study found that TXA reduced the need for urgent endoscopy and improved outcomes for patients with acute GI bleeding 2.
Reduction in Mortality and Rebleeding
- TXA has been shown to reduce mortality in patients with upper GI bleeding, with a relative risk (RR) of 0.72 (95% CI: 0.59-0.87) 5.
- A meta-analysis found that TXA significantly reduced rebleeding rates overall, with an RR of 0.81 (95% CI: 0.87-0.97) 5.
- TXA has also been found to reduce the need for surgical intervention in patients with GI bleeding, particularly in those with upper GI bleeding 5.
Safety and Adverse Events
- The use of TXA has been associated with an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism 6.
- However, other studies have found no significant increase in thromboembolic events with TXA use 3, 4, 5.
- The overall safety profile of TXA in patients with GI bleeding is still being studied, and more research is needed to fully understand its risks and benefits 6, 5.
Clinical Applications
- TXA may be a useful adjunctive treatment for patients with acute GI bleeding, particularly those with upper GI bleeding 2, 3, 5.
- The use of TXA should be individualized and based on patient-specific factors, including the severity of bleeding and the presence of comorbidities 5.
- Further research is needed to fully understand the efficacy and safety of TXA in patients with GI bleeding, particularly in those with lower GI bleeding 6, 5.