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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended for routine treatment of upper GI bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1

Evidence Assessment

The most recent and authoritative evidence from the European Association for the Study of the Liver (EASL) and other major gastroenterology societies strongly advises against the routine use of TXA in GI bleeding management. This recommendation is based on high-quality evidence showing:

• No mortality benefit from TXA in GI bleeding
• Increased risk of thromboembolic events (relative risk 1.85,95% CI 1.15-2.98) compared to placebo 1
• Particularly elevated risk in patients with liver disease or suspected variceal bleeding 1

Conflicting Evidence

While some older meta-analyses suggested potential benefits:

• A 2021 meta-analysis reported TXA reduced continued bleeding (RR=0.60), urgent endoscopic intervention (RR=0.35), and mortality (RR=0.60) 2
• A 2015 review concluded TXA probably decreases rebleeding and mortality 3

However, these findings are contradicted by the more recent and larger HALT-IT trial, which included 12,009 patients and found no beneficial effect of TXA on mortality or bleeding control while demonstrating increased thromboembolic risk 1.

Specific Contraindications

TXA has:

• Absolute contraindications in patients with recent thrombosis 1
• Relative contraindications in patients with atrial fibrillation and known thrombophilia 1

Recommended Approach for Upper GI Bleeding

Instead of TXA, the following evidence-based interventions are recommended:

1. Initial Assessment and Stabilization:

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

2. Pharmacological Management:

   • High-dose IV proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) after successful endoscopic therapy for ulcer bleeding 1
   • For suspected variceal bleeding, start vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 1

3. Endoscopic Management:

   • Perform endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) 1
   • Use endoscopic band ligation for variceal bleeding 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

Important Clinical Considerations

• For patients on direct oral anticoagulants (DOACs), interrupt these medications 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

Common Pitfalls to Avoid

• Administering TXA based on older, smaller studies despite newer evidence showing potential harm
• Failing to recognize that 10-15% of apparent lower GI bleeds are actually from upper GI sources 1
• Using large volumes of blood products in variceal bleeding, which may paradoxically increase portal pressure and worsen bleeding 1