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

From the Guidelines

Tranexamic acid (TXA) should not be used as a first-line treatment to stop a GI bleed, but it may be considered as an adjunctive therapy in certain cases, particularly when endoscopy is delayed or unavailable, based on the most recent evidence from 2021 1. When considering the use of TXA in GI bleeding, it's essential to understand its mechanism of action and potential benefits. TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites, making it particularly useful for mucosal bleeding in the GI tract. However, the primary management of GI bleeds should include proton pump inhibitors, endoscopic intervention for direct hemostasis, and correction of coagulopathies.

Some studies suggest that TXA may be beneficial in reducing mortality in upper GI bleeding, with a 40% risk reduction in mortality reported in pooled analysis 1. However, this benefit was no longer apparent when the analysis was limited to trials at low risk of bias, and the studies were considered historic, making their extrapolation to modern day care uncertain. More recent guidelines recommend systemic therapies, including TXA, for managing GI bleeding in specific patient populations, such as those with hereditary hemorrhagic telangiectasia (HHT) 1.

In the context of HHT-related GI bleeding, TXA is recommended for patients with mild GI bleeding due to its low potential for harm, although there is limited evidence of effectiveness 1. For patients with moderate or severe GI bleeding, systemic bevacizumab is recommended, which has shown substantial improvements in mean hemoglobin and reduced red cell transfusion requirements 1.

Key points to consider when using TXA in GI bleeding include:

• TXA is not a first-line treatment for most GI bleeds
• Primary management should include proton pump inhibitors, endoscopic intervention, and correction of coagulopathies
• TXA may be considered as an adjunctive therapy in certain cases, particularly when endoscopy is delayed or unavailable
• The use of TXA should be individualized based on patient-specific factors, such as the severity of bleeding and underlying medical conditions.

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 Implications

• The available evidence suggests that TXA may be a useful treatment for acute GI bleeding, particularly in patients with upper GI bleeding 2, 3, 4, 5.
• However, the decision to use TXA should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 6, 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.