Can Tranexamic Acid (TXA) stop an upper gastrointestinal (GI) bleed?

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended as routine therapy for upper GI bleeding as current guidelines do not support its use outside of clinical trials, despite some evidence suggesting it may reduce surgical intervention and mortality. 1, 2

Evidence Assessment

Guideline Recommendations

The British Society of Gastroenterology guidelines specifically note that while a meta-analysis has shown tranexamic acid therapy might reduce the need for surgical intervention and tends to reduce mortality in ulcer bleeding patients, further studies are necessary before it can be recommended as routine therapy 1. More recent guidelines continue to recommend that TXA use in GI bleeding should be confined to clinical trials 2.

Current Evidence

• A meta-analysis showed TXA appears to reduce the need for surgical intervention and tends to reduce mortality in ulcer bleeding patients, but does not reduce ulcer rebleeding 1
• The HALT-IT trial was designed to provide more definitive evidence about TXA effectiveness in acute upper and lower GI bleeding 3
• Some case reports suggest TXA may be beneficial in specific situations, such as in patients who cannot receive blood products 4
• A 2015 review concluded TXA probably decreases rebleeding and mortality without increasing thromboembolic adverse effects 5

Management Algorithm for Upper GI Bleeding

1. Initial Resuscitation

   • Fluid resuscitation to reverse hypovolemia
   • Blood transfusions as needed
   • Respiratory support if necessary

2. First-line Pharmacological Therapy

   • High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) 1, 2
   • Consider somatostatin in select cases, though evidence is limited 1
   • Do not use TXA as routine therapy 1, 2

3. Endoscopic Management

   • Early endoscopy for diagnosis and therapeutic intervention
   • Repeat endoscopy if clinical evidence of rebleeding 1

4. For Refractory Bleeding

   • If endoscopic therapy fails, consider interventional radiology or surgery 1
   • For patients who rebleed after initial stabilization, repeat endoscopy to confirm bleeding and attempt endoscopic therapy once more 1

Special Considerations

Patients on Anticoagulants

• For patients on direct oral anticoagulants with GI bleeding, temporarily interrupt the DOAC
• Consider specific reversal agents for life-threatening hemorrhage (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) 2
• TXA is not recommended as an alternative to proper anticoagulant management 2

Exceptional Circumstances

• While not recommended for routine use, TXA might be considered in exceptional circumstances such as:
  • Patients who refuse blood products (e.g., Jehovah's Witnesses) 4
  • As part of clinical trials 2, 3

Pitfalls and Caveats

• Do not delay endoscopy while waiting for TXA to take effect - early endoscopy remains the standard of care for diagnosis and treatment
• Do not substitute TXA for appropriate proton pump inhibitor therapy, which has stronger evidence supporting its use
• The evidence supporting TXA in GI bleeding is limited and potentially skewed by methodological issues in older studies 1
• Using TXA outside of clinical trials may delay the collection of high-quality evidence needed to determine its true efficacy

While some evidence suggests potential benefits of TXA in upper GI bleeding, current guidelines do not support its routine use, and management should focus on established interventions including proton pump inhibitors and early endoscopy.