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 does not reduce mortality and increases the risk of venous thromboembolic events, particularly in patients with liver disease. 1, 2

Current Evidence and Recommendations

Guidelines on TXA for GI Bleeding

• The British Society of Gastroenterology explicitly recommends against using tranexamic acid for gastrointestinal bleeding in routine clinical practice 1, 2
• The European Association for the Study of the Liver (EASL) strongly recommends against using tranexamic acid in patients with cirrhosis and active variceal bleeding 1
• Current guidelines emphasize standard therapies for upper GI bleeding:
  • Prompt resuscitation
  • Early endoscopic intervention
  • Proton pump inhibitors
  • Vasoactive drugs for variceal bleeding (terlipressin, somatostatin, octreotide)
  • Antibiotics in cirrhotic patients

Key Clinical Trial Evidence

• The HALT-IT trial (n=12,009) is the largest and most recent randomized controlled trial evaluating TXA in GI bleeding 2
  • Found no reduction in death due to bleeding within 5 days
  • Demonstrated a significant increase in venous thromboembolic events
  • Risk of thromboembolic events was particularly high in patients with liver disease/suspected variceal bleeding 1

Potential Mechanisms for TXA Ineffectiveness in GI Bleeding

• Limited role of fibrinolysis in the pathophysiology of variceal bleeding 1
• Hypofibrinolytic state often present in critically ill patients with cirrhosis 1
• Possible paradoxical increase in portal pressure with administration of blood products in cirrhotic patients 1

Special Considerations

Patients with Liver Disease

• TXA is particularly contraindicated in patients with liver disease due to:
  • Nearly 2-fold increase in venous thromboembolic events 1
  • No mortality benefit 1
  • Relative hypofibrinolysis often present in acute-on-chronic liver failure 1

Alternative Approaches

• For upper GI bleeding, focus on:
  • Early endoscopic intervention
  • Vasoactive drugs (for variceal bleeding)
  • Restrictive red blood cell transfusion strategy
  • Correction of severe coagulopathy on a case-by-case basis 1

Common Pitfalls

• Older meta-analyses suggesting benefit: Some older, smaller studies suggested TXA might reduce rebleeding and mortality 3, 4, but these have been superseded by the large HALT-IT trial 2
• Confusing with trauma guidelines: While TXA is beneficial in trauma bleeding, this benefit does not extend to GI bleeding 2
• Local administration: Even locally administered TXA shows no benefit over standard care for upper GI bleeding 5
• Surgical need reduction: Although some meta-analyses suggest TXA may decrease the need for surgery 6, this potential benefit is outweighed by the increased thromboembolic risk, especially in patients with liver disease

In conclusion, despite theoretical benefits of an antifibrinolytic agent in bleeding conditions, the evidence clearly demonstrates that tranexamic acid should not be used in the management of upper GI bleeding due to lack of mortality benefit and increased thromboembolic risk.