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 GI bleeding due to lack of mortality benefit and increased risk of thromboembolic events, particularly in patients with liver disease. 1

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) and other major societies strongly recommend against using TXA in upper GI bleeding, especially for variceal bleeding 1
• The 2021 American Association for the Study of Liver Diseases (AASLD) guidance specifically notes that a recent international multicenter, randomized trial showed no reduction in death or bleeding with TXA in acute gastrointestinal bleeding 2
• The AASLD guidance further highlights that the risk of venous thromboembolic events was higher in patients with cirrhosis receiving TXA 2

Risks vs. Benefits

Risks:

• Increased thromboembolic events with a relative risk of 1.85 (95% CI 1.15-2.98) compared to placebo 1
• Particularly high risk in patients with liver disease or suspected variceal bleeding 1
• Absolute contraindications in patients with recent thrombosis 1
• Relative contraindications in patients with atrial fibrillation and known thrombophilia 1

Potential Benefits:

• Some older and smaller studies suggested TXA might reduce rebleeding rates and need for surgery 3
• However, these potential benefits have not been confirmed in larger, more recent trials 1

Alternative Recommended Approaches for Upper GI Bleeding

Instead of TXA, current guidelines recommend:

1. Initial assessment and stabilization:

   • Use restrictive transfusion threshold of 70 g/L (aiming for 70-100 g/L) 1
   • Consider higher 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: vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 1
   • Prophylactic antibiotics for suspected variceal bleeding 1

3. Procedural interventions:

   • Early endoscopy with hemostasis for high-risk stigmata 1
   • Consider interventional radiology for ongoing bleeding not responding to endoscopic therapy 1

Important Clinical Considerations

• The HALT-IT trial, which was a large randomized controlled trial with 12,009 patients, found no beneficial effect of TXA on mortality or bleeding control in acute upper GI bleeding 1
• The same trial demonstrated an almost 2-fold increase in venous thromboembolic events in patients receiving TXA 1
• Avoid large volumes of blood products in variceal bleeding as they may paradoxically increase portal pressure 1
• For correction of coagulopathy in liver disease patients, vitamin K is recommended over fresh frozen plasma 2

Conclusion

Despite some earlier studies suggesting potential benefits, the most recent and highest quality evidence does not support the use of TXA for upper GI bleeding. The lack of mortality benefit combined with increased thromboembolic risk, particularly in patients with liver disease, makes TXA an inappropriate choice for routine management of upper GI bleeding.