Tranexamic Acid in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.
Review published in Critical care medicine (2022)
Abstract
OBJECTIVES: Tranexamic acid is proposed as a treatment for gastrointestinal bleeding. The Haemorrhage Alleviation with Tranexamic Acid-Intestinal System trial evaluated extended-use (24 hr) high-dose tranexamic acid, prompting a reappraisal for tranexamic acid in gastrointestinal bleeding. DATA SOURCES: We conducted a systematic review and meta-analysis of randomized controlled trials comparing tranexamic acid with usual care or placebo in adults with gastrointestinal bleeding. We searched MEDLINE, EMBASE, and CENTRAL (inception to September 2019). DATA SELECTION: Two reviewers independently screened citations, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool in duplicate. The main outcomes were mortality, bleeding, and adverse events. DATA EXTRACTION: Studies were analyzed as high-dose IV tranexamic acid versus all other dosing strategies for tranexamic acid using fixed-effects models. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS: Five randomized controlled trials evaluated extended-use high-dose IV tranexamic acid, seven evaluating low-dose IV or enteral tranexamic acid. Extended-use high-dose IV tranexamic acid did not reduce mortality (relative risk, 0.98%; 95% CI, 0.88-1.09; I2 = 63%; high certainty) or bleeding (relative risk, 0.92; 95% CI, 0.82-1.04; p = 0.17 and absolute risk differences, -0.7%; 95% CI, -1.5 to 0.3; high certainty) but resulted in a small increase in deep venous thrombosis (relative risk, 2.01; 95% CI, 1.08-3.72; I2 = 0%), pulmonary embolism (relative risk, 1.78; 95% CI, 1.06-3.0; I2 = 0%), and seizure (relative risk, 1.73; 95% CI, 1.03-2.93) with high certainty. Low-dose IV/enteral tranexamic acid did not reduce mortality (relative risk, 0.62; 95% CI, 0.36-1.09; I2 = 0%) but did reduce risk of rebleeding (relative risk, 0.5; 95% CI, 0.33-0.75; I2 = 9%) and need for surgery (relative risk, 0.58; 95% CI, 0.38-0.88; I2 = 11%), with moderate certainty. CONCLUSIONS: Extended-use high-dose IV tranexamic acid does not improve mortality or bleeding outcomes and increases adverse events. Low-dose/enteral tranexamic acid may be effective in reducing hemorrhage; more evidence is required to demonstrate its safety.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Tranexamic acid is proposed as a treatment for gastrointestinal bleeding. The Haemorrhage Alleviation with Tranexamic Acid-Intestinal System trial evaluated extended-use (24 hr) high-dose tranexamic acid, prompting a reappraisal for tranexamic acid in gastrointestinal bleeding.
Why This Matters for Hirudotherapy
This systematic review and meta-analysis of randomized controlled trials evaluated tranexamic acid for gastrointestinal bleeding and found that extended-use high-dose IV tranexamic acid did not reduce mortality (RR 0.98) or bleeding (RR 0.92) but increased deep vein thrombosis, pulmonary embolism, and seizures (high certainty), while low-dose IV/enteral dosing reduced rebleeding (RR 0.5) and need for surgery (RR 0.58) with moderate certainty though without a mortality benefit. For ASH it is a cautionary, methodologically rigorous reference point on the opposite end of the hemostatic spectrum from anticoagulant leech-derived agents, demonstrating that pushing clotting too far (here, via an antifibrinolytic) carries real thrombotic harm, mirroring the bleeding-versus-clotting balance that defines anticoagulant drug discovery. The study concerns tranexamic acid, not leeches or hirudotherapy, and even as high-certainty evidence it speaks only to that drug, not to leech-based interventions.
Citation
Tranexamic Acid in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.
Dionne JC et al. · Critical care medicine, 2022
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