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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended for upper GI bleeding as it shows no mortality benefit while increasing the risk of venous thromboembolic events, particularly in patients with liver disease. 1

Evidence Assessment and Recommendation

The British Society of Gastroenterology and the European Association for the Study of the Liver strongly recommend against using tranexamic acid for gastrointestinal bleeding in routine clinical practice 1. This recommendation is based on high-quality evidence from the HALT-IT trial, which found:

• No reduction in death due to bleeding within 5 days
• A significant increase in venous thromboembolic events
• Nearly 2-fold increase in thromboembolic complications in patients with liver disease 1

Conflicting Evidence

While some older meta-analyses suggested potential benefits:

• A 2021 meta-analysis of 13 randomized controlled trials 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 without increasing thromboembolic events 3

However, these findings have been superseded by the HALT-IT trial, which was specifically designed to address methodological weaknesses in previous smaller studies 4.

Recent Evidence

More recent evidence further confirms the lack of benefit:

• A randomized controlled trial examining local administration of TXA found no statistically significant difference in composite outcomes (rebleeding, recurrent endoscopy, mortality) between TXA and control groups (32.1% vs 29.1%) 5
• A 2021 systematic review found TXA may decrease rebleeding (RR=0.64) and need for surgery (RR=0.59) but showed no statistically significant effect on mortality (RR=0.95) or thromboembolic events (RR=0.93) 6

Recommended Management Approach for Upper GI Bleeding

Instead of TXA, standard therapies for upper GI bleeding should include:

1. Prompt resuscitation and hemodynamic stabilization

   • Restrictive red blood cell transfusion strategy (threshold of 70 g/L, target 70-100 g/L)
   • Consider higher transfusion threshold in patients with cardiovascular disease

2. Early endoscopic intervention

   • Critical for both diagnosis and therapeutic management

3. Pharmacological therapy

   • Proton pump inhibitors for non-variceal bleeding
   • Vasoactive drugs for variceal bleeding

4. Correction of coagulopathy on a case-by-case basis

5. Interventional radiology or surgery for refractory bleeding 1

Important Considerations

• Up to 15% of patients with severe hematochezia may have an upper GI source, highlighting the importance of not assuming lower GI bleeding is truly from a lower source 1
• TXA is particularly contraindicated in patients with liver disease due to the increased risk of thromboembolic events 1
• While TXA is beneficial in trauma-related bleeding, this benefit does not extend to GI bleeding 1

Clinical Pitfalls to Avoid

• Don't administer TXA to patients with suspected or confirmed liver disease/cirrhosis as it significantly increases thromboembolic risk
• Don't assume TXA's benefits in trauma bleeding apply to GI bleeding contexts
• Don't rely on older, smaller studies when more recent, larger trials provide contradictory evidence
• Don't delay endoscopic intervention while trying pharmacological approaches