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 the risk of thromboembolic events, particularly in patients with liver disease. 1, 2

Evidence Against TXA in Upper GI Bleeding

Guidelines Recommendations

• 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 1, 2
• The British Society of Gastroenterology states that TXA use in acute LGIB should be confined to clinical trials 1
• Current guidelines indicate TXA is not recommended as routine therapy for GI bleeding due to lack of mortality benefit and increased risk of thromboembolic events 2

Key Evidence

• A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding showed:
  • No beneficial effect of TXA on mortality 1
  • Almost 2-fold increase in venous thromboembolic events in the TXA group 1
  • Risk of venous thromboembolic events was particularly concentrated in patients with liver disease/suspected variceal bleeding 1

Reasons for TXA Ineffectiveness in GI Bleeding

• Limited role of fibrinolysis in variceal bleeding mechanisms 1
• Frequent occurrence of hypofibrinolytic state in critically ill patients with cirrhosis 1
• Potential for paradoxical increase in bleeding risk due to thrombotic complications 1

Standard of Care for Upper GI Bleeding

Instead of TXA, the standard therapy for upper GI bleeding should include:

• For non-variceal bleeding:

  • High-dose IV proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) following endoscopic therapy 2
  • Endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) 2

• For variceal bleeding:

  • Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 1, 2
  • Prophylactic antibiotics 2
  • Endoscopic band ligation 1
  • Restrictive transfusion strategy (target hemoglobin 70-90 g/L) 2

Cautions and Contraindications

• TXA has absolute contraindications in patients with recent thrombosis 2
• TXA has relative contraindications in patients with atrial fibrillation and known thrombophilia 2
• In patients with cirrhosis, large volumes of blood products may paradoxically increase portal pressure and worsen bleeding 1, 2

While some older meta-analyses suggested potential benefits of TXA in reducing rebleeding 3, 4, 5, these findings have been superseded by more recent, larger, and higher-quality studies that show no mortality benefit and increased thrombotic risk. The most recent and highest quality evidence strongly recommends against TXA use in upper GI bleeding.