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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended for routine use in upper gastrointestinal bleeding as it shows no mortality benefit and may increase thromboembolic risk, particularly in patients with liver disease. 1, 2

Evidence Assessment

The most recent and highest quality evidence comes from guidelines that specifically address this question:

• The European Association for the Study of the Liver (EASL) 2022 guidelines strongly recommend against using tranexamic acid in variceal bleeding due to increased risk of thromboembolic events 1
• The British Society of Gastroenterology (2019) suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 1

Mechanism and Rationale

Tranexamic acid is an antifibrinolytic agent that works by inhibiting the breakdown of fibrin clots. While this mechanism is effective in certain bleeding scenarios (such as trauma and surgical bleeding), its application in GI bleeding is more complex:

• In variceal bleeding, hemostasis plays a limited role in the bleeding mechanism 1
• Patients with cirrhosis often have a hypofibrinolytic state, making antifibrinolytics potentially harmful 1

Key Clinical Evidence

A large randomized placebo-controlled trial (HALT-IT) including 12,009 patients with acute upper GI bleeding found:

• No beneficial effect of TXA on mortality or bleeding control 1, 2
• Almost 2-fold increase in venous thromboembolic events in patients receiving TXA compared to placebo 1, 2
• The risk of thromboembolic events was particularly concentrated in patients with liver disease/suspected variceal bleeding 1, 2

Patient-Specific Considerations

Contraindications to TXA in GI Bleeding:

• Absolute contraindication in patients with recent thrombosis 2
• Relative contraindication in patients with atrial fibrillation and known thrombophilia 2
• Strong contraindication in patients with liver disease or variceal bleeding 1

Alternative Management Approaches for Upper GI Bleeding:

1. First-line treatments:

   • Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy for suspected variceal bleeding 1
   • High-dose IV proton pump inhibitor therapy for non-variceal bleeding 2
   • Endoscopic intervention for direct hemostasis 2

2. Blood product management:

   • Use restrictive transfusion strategy (target Hgb 70-100 g/L) 2
   • Avoid large volumes of blood products in patients with cirrhosis as they may paradoxically increase portal pressure 1

Clinical Bottom Line

Despite some older studies suggesting potential benefits, the most recent high-quality evidence clearly demonstrates that TXA does not improve mortality in upper GI bleeding and may increase thromboembolic complications. The standard of care remains prompt endoscopic intervention, vasoactive drugs when appropriate, and supportive care with judicious blood product administration.

Clinicians should focus on established effective interventions rather than adding TXA to the management algorithm for upper GI bleeding.