Tranexamic acid as treatment for acute gastrointestinal bleeding: A comprehensive systematic review and meta-analysis

Gastrointestinal (GI) bleeding is a common and potentially life-threatening medical emergency. Despite advancements in therapy, mortality rates associated with GI bleeding remain high (2.4% to 11%). Tranexamic acid (TXA) has been proposed as a treatment. However, the HALT-IT trial questioned its efficacy and safety, showing no significant reduction in death and potential thrombotic complications. This meta-analysis aims to evaluate the effectiveness and safety of TXA in treating acute GI bleeding.

This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. In October 2024 a comprehensive literature search was conducted using relevant MeSh terms and keywords in 11 databases. We included patients with acute GI bleeding treated with TXA and compared it with either a placebo or standard treatment. Outcomes such as mortality, need for blood transfusion, surgery and thrombotic events were studied.

The search identified 6810 articles. After screening, 23 studies were included, encompassing 2,061,231 participants. Our meta-analysis demonstrated that TXA significantly reduced rebleeding rates overall (RR: 0.81, 95% CI: 0.87-0.97). This effect was even more pronounced in studies with a lower risk of bias. Additionally, TXA use was associated with a mortality reduction when administered through both oral and intravenous routes (RR: 0.56, 95% CI: 0.35-0.89) and in cases of upper GI bleeding (RR: 0.72, 95% CI: 0.59-0.87). However, TXA was linked to a significant increase in mortality in patients with lower GI bleeding (RR: 1.67, 95% CI: 1.44-1.93) and overall reduction when only randomized controlled trials (RCTs) were included (RR:0.83, 95% CI; 0.70 to 0,97, I2=0%). Other variables, such as the overall need for blood transfusions (RR: 1.03, 95% CI: 0.80-1.32), thrombotic events (RR: 1.30, 95% CI: 0.75-2.23) and the need for surgical intervention (RR: 0.78, 95% CI: 0.57-1.09), did not reach statistical significance. However, when considering only low risk of bias studies the need for surgical interventions was significantly reduced (RR: 0.85, 95% CI: 0.75 to 0.97, I2=0%).

Our findings suggest that TXA significantly reduces rebleeding in patients, particularly in upper gastrointestinal bleeding (UGIB) and reduces need for surgical intervention when excluding high risk of bias studies. The findings also demonstrated a significant reduction in mortality, particularly in certain sub-groups. There was no definitive evidence that its use is associated with thromboembolictic events. These results highlight the potential benefit of TXA without dismissing the need for cautious interpretation and individualized patient management when considering TXA for GI bleeding.