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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) should NOT be used routinely 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 Use in Upper GI Bleeding

Clinical Trial Evidence

• A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding showed:
  • No beneficial effect of tranexamic acid on mortality 1
  • No benefit in the subgroup analysis of patients with suspected variceal bleeding and liver disease 1
  • Almost 2-fold increase in venous thromboembolic events in the TXA group compared to placebo 1
  • Higher risk of venous thromboembolic events specifically in patients with comorbid liver disease/suspected variceal bleeding 1

Guideline 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 American Association for the Study of Liver Diseases (AASLD) states that until further supportive data are published, prophylactic use of TXA to prevent procedural bleeding cannot be recommended 1

Special Considerations for Different Types of GI Bleeding

Variceal Bleeding

• TXA is specifically contraindicated in variceal bleeding 1
• Standard therapy for variceal bleeding should include:
  • Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy
  • Antibiotics
  • Endoscopic band ligation 1

Non-Variceal Upper GI Bleeding

• Standard treatment should focus on:
  • Endoscopic hemostasis for high-risk stigmata
  • High-dose IV proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) following successful endoscopic therapy 2
  • Restrictive transfusion strategy (target hemoglobin 70-100 g/L) 2

Conflicting Evidence from Older Studies

Some older and smaller studies suggested potential benefits of TXA in upper GI bleeding:

• Reduced rebleeding rates 3, 4
• Decreased need for surgery 4

However, these findings have been superseded by the more recent, larger, and higher-quality trials showing no mortality benefit and increased thromboembolic risk 1, 2.

Clinical Pitfalls to Avoid

• Do not use TXA as a substitute for definitive endoscopic therapy
• Be particularly cautious about TXA use in patients with liver disease due to higher thromboembolic risk
• Do not delay standard treatments (endoscopy, PPIs, vasoactive drugs) while considering TXA
• Remember that large volumes of blood products may paradoxically increase portal pressure in patients with varices 1

In summary, despite some theoretical benefits and conflicting older evidence, current high-quality guidelines strongly recommend against routine use of TXA for upper GI bleeding, particularly in patients with liver disease or variceal bleeding.