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 it does not reduce rebleeding rates, though it may reduce surgical intervention and mortality in some cases. 1

Evidence Assessment

The current guidelines from the British Society of Gastroenterology do not support routine use of tranexamic acid for upper GI bleeding. While meta-analyses have shown some potential benefits, the evidence quality is considered insufficient to recommend its routine use.

What the Guidelines Say:

• According to the 2002 British Society of Gastroenterology guidelines, tranexamic acid therapy appears to reduce the need for surgical intervention and tends to reduce mortality in ulcer bleeding patients, but does not reduce ulcer rebleeding rates 1
• The meta-analysis supporting these findings was likely skewed by inclusion of an extremely large trial with unusually high mortality in the control group 1
• The 2019 British Society of Gastroenterology guidelines for lower GI bleeding recommend that tranexamic acid use should be confined to clinical trials 1
• Current practice recommendations suggest that further studies are necessary before tranexamic acid can be recommended as routine therapy 2

Research Evidence:

While some newer research suggests potential benefits:

• A 2021 systematic review found TXA significantly reduced continued bleeding (RR = 0.60), urgent endoscopic intervention (RR = 0.35), and mortality (RR = 0.60) compared with placebo 3
• Another 2021 systematic review found TXA decreased rebleeding risk (RR = 0.64) and need for surgery (RR = 0.59), but did not significantly affect mortality (RR = 0.95) or thromboembolic events (RR = 0.93) 4

However, conflicting evidence exists:

• A 2020 randomized controlled trial of locally administered TXA found no additional benefit over standard care for upper GI hemorrhage 5

Management Algorithm for Upper GI Bleeding

1. First-line treatment:

   • High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) 1, 2
   • Early endoscopy for diagnosis and therapeutic intervention 2

2. For rebleeding after initial stabilization:

   • Repeat endoscopy to confirm bleeding and attempt endoscopic therapy once more 1, 2
   • Consider interventional radiology or surgery for uncontrolled hemorrhage that cannot be stopped by endoscopic intervention 1, 2

3. Role of tranexamic acid:

   • Not recommended as routine therapy 1, 2
   • May be considered in specific clinical trial settings 1
   • Should not be used as a substitute for definitive endoscopic therapy

Pitfalls and Caveats

• Do not delay endoscopic therapy while waiting for potential benefits from TXA
• The evidence for TXA in upper GI bleeding is of lower quality compared to its established role in trauma
• Potential thromboembolic complications must be considered, especially in patients with cardiovascular disease
• For patients on anticoagulants with GI bleeding, focus should be on temporarily interrupting the anticoagulant and using specific reversal agents if necessary, rather than adding TXA 2

In conclusion, while tranexamic acid shows some promise in reducing surgical intervention and possibly mortality in upper GI bleeding, the current guidelines do not support its routine use outside of clinical trials. The cornerstone of management remains prompt endoscopic intervention and high-dose proton pump inhibitor therapy.