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How effective is tranexamic acid

for acute gastrointestinal


bleeding?
http://www.bmj.com/
Jecko Thachil, Consultant Haematologist
Manchester Royal Infirmary, Oxford road, Manchester, M13 9WL
10 March 2014
In the timely article by Manno and colleagues, it is stated that tranexamic
acid MAY be associated with an increased risk of thrombosis, but
reassures us by saying the risk is imprecise and compatible with the
play of chance [1]. This baseless fear of causing thrombosis is echoed
in several other clinical situations where tranexamic acid has been found
to be extremely effective.
Tranexamic acid inhibits fibrinolysis which commences after the
formation of a clot in order to limit the progression of thrombus away
from the site of bleeding. In clinical scenarios of excess bleeding, the
large amounts of clot formed are extremely fragile and tranexamic acid is
extremely beneficial to firm up the thrombus. And this has been
confirmed in the well-known CRASH trial and its use has been extended
with evidence for benefit in cardiac surgery, trauma, liver surgery,
neurosurgery, and obstetric haemorrhage [2,3].
In the clinical situations where the clotting mechanism is activated
systemically (not locally) as with disseminated intravascular coagulation
(DIC), fibrinolysis sets in to clear the circulation of the extensive clots.
Tranexamic acid can be deleterious in this setting. In the setting of
trauma, this balance towards clotting rather than hyperfibrinolysis can
occur after a critical period of time, when tranexamic acid can be
dangerous [4].
What does this mean? A better understanding of the pathophysiological
process is necessary in the use of tranexamic acid at the right time and
in the right situation. The right time is early and the right situations can
be any condition where there is extensive blood loss, but no systemic
unbalanced coagulation activation. However, an unnecessary fear of
thrombosis should not dissuade us from using a cheap, but very
effective drug.
References
1.Manno D, Ker K, Roberts I. How effective is tranexamic acid for acute
gastrointestinal bleeding? BMJ. 2014 Feb 17;348:g1421.
2.Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on
death, vascular occlusive events, and blood transfusion in trauma
patients with significant haemorrhage (CRASH-2): a randomised,
placebo-controlled trial. Lancet 2010; 376: 2332.
3.Ortmann E, Besser MW, Klein AA. Antifibrinolytic agents in current
anaesthetic practice. Br J Anaesth. 2013 Oct;111(4):549-63.
4.Gando S, Sawamura S, Hayakawa M. Trauma, shock, and
disseminated intravascular coagulation. Ann Surg 2011; 254: 109.