#313 Gastrointestinal bleeding – Does tranexamic acid halt it or not?
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- High quality, international, randomized controlled trial (RCT) of 12009 patients with significant acute (signs of shock or likely to require transfusion, endoscopy or surgery) gastrointestinal bleed (90% upper).1 Patients (mean age 58 years, 64% males) randomized to 1-gram intravenous tranexamic acid (TXA), followed by 3g infusion over 24-hours or placebo. Outcomes not statistically different at 28 days:
- All-cause mortality: 9.5% versus 9.2% placebo
- Death from gastrointestinal bleeding: 4.2% versus 4.4% placebo
- Transfused units of whole blood or red cells: 2.8 versus 2.9 placebo
- Proportion requiring surgical intervention 87.6% versus 87.5% placebo
- Days in intensive care: 1.8 days versus 2.0 placebo
- Thromboembolic events: 1.4% versus 1.2% placebo.
- Limitations: Other care provided was not explicitly stated and likely differed between countries.
- Systematic review done prior to above RCT (8 studies, 1701 patients)2 found 5-day mortality benefit with TXA but is limited by:
- Small number of patients (total ~15% of above RCT),
- Benefit disappeared when patients lost to follow up were conservatively analyzed.
- Peptic ulcer disease, gastritis, esophageal varices and Mallory-weiss tears are the most common etiologies of upper gastrointestinal bleeds.3,4
- Upper gastrointestinal bleed mortality has been decreasing since late 20th century; is currently ~2%.3
- Proton pump inhibitors given prior to endoscopy may decrease the need for endoscopic treatments but have not been shown to decrease mortality.5
- Restrictive transfusion strategies (example transfusing hemoglobin at 70-80 g/L versus 90-100 g/L) does not negatively affect mortality or other outcomes.6
- Performing gastroscopies for upper gastrointestinal bleeds within 24 hours has similar outcomes as performing them within 6 hours.7