When to Give Tranexamic Acid

The second new article on this topic represents a possible change in practice many of us have likely adopted or considered adopting already: Should emergency physicians be giving tranexamic acid (TXA) to patients with acute gastrointestinal bleeding?³ After all, we’ve been giving it to patients with major bleeding in trauma, as well as considering it to be likely beneficial for those with severe head injuries and postpartum hemorrhage.^4–6

Like other TXA trials, this latest trial was a massive undertaking, enrolling nearly 12,000 patients over six years across 164 hospitals. Patients were eligible for inclusion based on pragmatic, subjective clinical assessment. To be included, patients simply needed to be judged likely to have a significant or life-threatening gastrointestinal bleed. Disease severity was assessed using the Rockall Score, which differs from the GBS as it incorporates findings identified at endoscopy as well as clinical presentation. Overall, however, patients appeared similarly ill as the endoscopy study above when accounting for tachycardia, melena, and signs of shock.

In contrast to the other TXA trials, unfortunately, there is simply no way to parse these results in a fashion favoring the intervention. Whether measured in deaths due to bleeding, recurrent bleeding, or all-cause mortality, outcomes were virtually identical. A majority of patients required transfusion, and these transfusion requirements were not altered by whether TXA was given. Adverse events were rare, but a small excess of venous thromboembolic events was seen in the cohort receiving TXA. The absolute difference, even in this study of 12,000 patients, was just a handful but likely does reflect an increased risk for venous thromboembolism in those receiving TXA.

Considering neither the CRASH-2 nor WOMAN trial detected an increase in thromboembolic events, the risk seen with TXA here is likely related to this specific population enrolled with gastrointestinal bleeding. Conceptually, this makes sense. Nearly half the patients enrolled were described as having liver disease severe enough to be judged to potentially result in variceal bleeding. Patients with advanced liver disease maintain a balance of deranged hemostasis, with relative excess and absence of coagulation factors and components. It is likely that hypofibrinolytic underlying states tipped off-balance by TXA resulted in the observed increases in venous thromboembolism. Regardless of liver functional status, however, absent a detectable benefit for TXA in gastrointestinal bleeding, this trial reveals that this medication has no apparent role in the treatment of GIB.

Conclusions

In sum, we have two potentially practice-changing conclusions. First, even a very ill patient with UGIB undergoing transfusion may be managed medically for an extended period of time prior to a decision to perform an endoscopy, rather than requiring urgent intervention, provided they are hemodynamically stable. Second, if you’ve been extrapolating the potential advantage of TXA from other clinical applications to your gastrointestinal bleeding patients, it seems clear this is unlikely to help and may even result in a small amount of harm in a subset of patients.

The opinions expressed here are solely those of Dr. Radecki and do not necessarily reflect those of his employer or academic affiliates.