From the Guidelines
Tranexamic acid is not routinely recommended for bleeding peptic ulcers. The standard treatment for bleeding peptic ulcers includes proton pump inhibitors (such as omeprazole 80mg IV bolus followed by 8mg/hr infusion for 72 hours) 1, endoscopic therapy (such as epinephrine injection, thermal coagulation, or clip placement), and supportive care including blood transfusions if needed. While tranexamic acid is an antifibrinolytic agent that helps stabilize blood clots and is effective for certain types of bleeding, clinical evidence does not support its routine use specifically for peptic ulcer bleeding. Studies have shown inconsistent results regarding its efficacy in this condition, with most guidelines not including it in standard management protocols 1. The primary mechanism of action of tranexamic acid is inhibiting plasminogen activation, which prevents clot breakdown, but this may not address the underlying pathophysiology of peptic ulcer bleeding, which often requires direct endoscopic intervention to treat the bleeding vessel. If bleeding is severe and endoscopy is delayed, general resuscitative measures and proton pump inhibitor therapy should be prioritized over tranexamic acid.
Key Considerations
- The most recent and highest quality study on this topic is from 2020, which suggests that proton pump inhibitors and endoscopic therapy are the mainstays of treatment for bleeding peptic ulcers 1.
- Tranexamic acid has been shown to have inconsistent results in reducing rebleeding and mortality in peptic ulcer bleeding, and its use is not recommended as routine therapy 1.
- Endoscopic therapy, such as epinephrine injection, thermal coagulation, or clip placement, is recommended to achieve hemostasis and reduce re-bleeding, the need for surgery, and mortality 1.
- Risk stratification using the Blatchford score can help guide management, with very low-risk patients potentially being managed as outpatients and high-risk patients requiring urgent inpatient endoscopy 1.
Management Priorities
- Airway control, breathing, circulation, and endoscopy are the key components of non-operative management for bleeding peptic ulcers 1.
- Proton pump inhibitors, such as omeprazole, should be started as soon as possible and continued for 72 hours after endoscopic therapy 1.
- Endoscopic therapy should be performed as soon as possible, with dual modality therapy (e.g. epinephrine injection and clip placement) being preferred over single modality therapy 1.
From the Research
Role of Tranexamic Acid in Managing Bleeding Peptic Ulcers
- Tranexamic acid (TXA) has been investigated as a potential adjunct to endoscopic hemostasis in the management of bleeding peptic ulcers 2.
- A randomized controlled trial found that topical TXA via endoscopic procedures may be effective in cases of GI bleedings caused by active bleeding ulcers, although larger studies are needed to confirm this effect 3.
- Another study found that the precise application of topical TXA to bleeding ulcers during endoscopic hemostasis reduced the early treatment failure rate in patients with peptic ulcer bleeding 4.
- A meta-analysis of randomized controlled trials found that TXA with acid suppression significantly reduced the risk of rebleeding, units of blood transfused, and the need for salvage therapy in patients with upper gastrointestinal bleeding 5.
- A retrospective cohort study found that TXA was more often prescribed to patients with more severe gastrointestinal bleeding ulcer disease, although the prescription of TXA has declined over time 6.
Key Findings
- TXA may be effective in reducing rebleeding and improving outcomes in patients with bleeding peptic ulcers 3, 4, 5.
- The combination of TXA with acid suppression may be a useful first-line therapy for upper gastrointestinal bleeding 5.
- Further studies are needed to determine the optimal dose and route of TXA administration for the management of bleeding peptic ulcers 3, 5.