Can tranexamic acid (TXA) stop an upper gastrointestinal (GI) bleed?

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) should not be used for upper gastrointestinal bleeding as it shows no mortality benefit and increases thromboembolic risk, particularly in patients with liver disease. 1, 2

Evidence Assessment

Efficacy and Safety Concerns

• The European Association for the Study of the Liver (EASL) strongly recommends against TXA use in variceal bleeding due to increased risk of thromboembolic events 2
• A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding showed no beneficial effect of TXA on mortality 2
• In patients with suspected variceal bleeding and liver disease, TXA was associated with almost a 2-fold increase in venous thromboembolic events compared to placebo 2
• The British Society of Gastroenterology guidelines note that tranexamic acid use in acute LGIB should be confined to clinical trials 2

Pathophysiological Considerations

• The ineffectiveness of TXA in GI bleeding may be explained by:
  • Limited role of haemostasis in variceal bleeding 2
  • Frequent occurrence of hypofibrinolytic state in critically ill patients with cirrhosis 2
  • Relative hypofibrinolysis observed in acute-on-chronic liver failure 2

Management Algorithm for Upper GI Bleeding

1. Initial Resuscitation

   • Assess hemodynamic stability
   • Use restrictive transfusion threshold (70 g/L, aiming for 70-100 g/L) 1
   • Consider higher transfusion threshold for patients with cardiovascular disease 1

2. Pharmacological Management

   • Administer high-dose IV proton pump inhibitors (80 mg stat followed by 8 mg/hour infusion for 72 hours) 1
   • For suspected variceal bleeding: start vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 2
   • Administer prophylactic antibiotics for suspected variceal bleeding 2

3. Endoscopic Management

   • Perform early endoscopy for diagnosis and therapeutic intervention 1
   • Apply endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) 1

4. Rescue Therapies

   • Consider interventional radiology for ongoing bleeding not responding to endoscopic therapy 1
   • Surgical intervention should be considered for uncontrolled hemorrhage after failed endoscopic and radiological approaches 1

Special Considerations

Anticoagulation Management

• Interrupt direct oral anticoagulants at presentation 1
• For life-threatening hemorrhage on DOACs, consider specific reversal agents like idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors) 1
• Restart anticoagulation approximately 7 days after hemorrhage if the bleeding source has been controlled 1

Patients with Cirrhosis

• TXA is specifically contraindicated in patients with cirrhosis and variceal bleeding due to increased thromboembolic risk 2, 1
• Avoid large volumes of blood products as they may paradoxically increase portal pressure and worsen bleeding 2

Conclusion

Despite some older studies suggesting potential benefits of TXA in reducing rebleeding rates 3, 4, 5, the most recent and highest quality evidence from large randomized controlled trials demonstrates no mortality benefit and increased thromboembolic risk with TXA use in upper GI bleeding 2, 1. Therefore, TXA should not be used as part of the standard management protocol for upper GI bleeding.