Joanna Dionne, MD, MS, BN
Fellow
McMaster University
Toronto, Ontario, Canada
Disclosure information not submitted.
Simon Oczkowski, MD, MS
Associate Professor
McMaster University, Canada
Disclosure information not submitted.
Beverly Hunt, MD, FRCP, OBE
Professor
King’s Healthcare Partners, London, United Kingdom and Guy’s & St Thomas’ Thrombosis & Haemophilia Centre, London, United Kingdom, United Kingdom
Disclosure information not submitted.
Massimo Antonelli, MD
Professor
Fondazione Policlinico Universitario A. Gemelli IRCCS, Italy
Disclosure information not submitted.
Title: Tranexamic acid in gastrointestinal bleeding
Introduction: Tranexamic acid (TXA) is proposed as a treatment for gastrointestinal bleeding (GIB). The HALT-IT trial evaluated extended-use (24 hour) high-dose TXA, prompting a reappraisal for TXA in GIB management.
Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing TXA to usual care or placebo in adults with GIB. 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 TXA vs. all other dosing strategies for TXA using fixed-effects models. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.
Results: 5 RCTs evaluated extended-use high-dose IV TXA, 7 evaluating low dose IV or enteral TXA. Extended-use high-dose IV TXA did not reduce mortality (RR 0.98% 95%CI 0.88-1.09, I2 =63%, high certainty), or bleeding (RR 0.92, 95%CI 0.82-1.04, p=0.17; ARD -0.7% 95%CI -1.5- 0.3; high certainty), but resulted in a small increase in DVT (RR 2.01, 95%CI 1.08-3.72, I2=0%), PE (RR 1.78, 95%CI 1.06-3.0, I2=0%), and seizure (RR 1.73, 95%CI 1.03-2.93) with high certainty. Low-dose IV/enteral TXA did not reduce mortality (RR 0.62, 95%CI 0.36-1.09, I2=0%), but did reduce risk of rebleeding (RR 0.5, 95% CI 0.33-0.75, I2=9%) and need for surgery (RR 0.58, 95%CI 0.38-0.88, I2=11%), with moderate certainty.
Conclusion: Extended-use high-dose IV TXA does not improve mortality or bleeding outcomes, and increases adverse events. Low-dose/enteral TXA may be effective in reducing hemorrhage, more evidence is required to demonstrate its safety.