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

From the Guidelines

Tranexamic acid (TXA) should not be used to stop an upper gastrointestinal (GI) bleed, particularly in patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect and may increase the risk of venous thromboembolic events 1. The use of TXA in upper GI bleeding has been evaluated in several studies, but the most recent and highest quality evidence comes from a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding, which found no beneficial effect of TXA in reducing mortality due to bleeding within the first 5 days 1. Key points to consider when managing upper GI bleeding include:

• The primary goal is to achieve hemostasis and prevent rebleeding, which can be achieved through a combination of endoscopic therapy, vasoactive medications, and correction of coagulopathy if present.
• In patients with cirrhosis and active variceal bleeding, the use of vasoactive therapy, such as terlipressin, somatostatin, or octreotide, is recommended, along with antibiotics and early endoscopic treatment.
• The use of blood products, such as platelets and fresh frozen plasma, should be guided by thromboelastography (TEG) results and reserved for patients with severe hemostatic abnormalities.
• TXA is not recommended due to its lack of efficacy and potential increased risk of thrombotic events, particularly in patients with comorbid liver disease or suspected variceal bleeding 1. Overall, the management of upper GI bleeding requires a multifaceted approach, and the use of TXA is not supported by current evidence as a beneficial adjunctive treatment.

From the Research

Efficacy of Tranexamic Acid in Upper GI Bleed

• Tranexamic acid (TXA) has been studied as a potential treatment for upper gastrointestinal (GI) bleeding, with some studies suggesting its efficacy in reducing bleeding and mortality 2, 3.
• A 2003 pilot study found that TXA was beneficial in treating major upper GI bleeding in dialysis patients, reducing the rate of early re-bleeding and the need for blood transfusions 2.
• A 2012 systematic review found that TXA reduced mortality compared to placebo, but the beneficial effect was not confirmed in subgroup analysis or worst-case scenario analyses 4.
• A 2008 systematic review suggested that TXA may reduce all-cause mortality, but the evidence was limited by the internal and external validity of the included trials 5.
• A 2021 systematic review with meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 3.
• A 2023 randomized clinical trial found that TXA was associated with a lower rate of rebleeding and hospitalization time, without significant adverse effects, but had no effect on mortality associated with severe upper GI bleeding 6.

Mechanism of Action

• TXA works as an antifibrinolytic agent, reducing hemorrhage by inhibiting the breakdown of fibrin clots 4, 3.

Safety and Adverse Effects

• The studies found no significant increase in thromboembolic events or adverse effects with the use of TXA 4, 5, 6.
• However, the evidence on the safety and efficacy of TXA in patients with GI bleeding is still limited, and further studies are needed to confirm its benefits and risks 4, 5.