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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) should NOT be used for the management of upper gastrointestinal bleeding as it does not reduce mortality or rebleeding rates and may increase thromboembolic complications. 1

Evidence Against TXA in Upper GI Bleeding

The most recent and high-quality evidence strongly recommends against the routine use of TXA in upper GI bleeding:

• The American College of Physicians recommends against routine use of high-dose IV TXA in gastrointestinal bleeding 1
• The European Association for the Study of the Liver (EASL) specifically states that "In patients with cirrhosis and active variceal bleeding, tranexamic acid should not be used" (Level of Evidence 2, strong recommendation) 2
• A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding showed no beneficial effect of TXA in the whole group or in the subgroup of patients with suspected variceal bleeding and liver disease 2

Risks of TXA in Upper GI Bleeding

Using TXA in upper GI bleeding carries significant risks:

• Almost 2-fold increase in venous thromboembolic events compared to placebo, particularly concentrated in patients with liver disease/suspected variceal bleeding 2, 1
• Increased risk of specific adverse events including:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

Conflicting Evidence

Some older or smaller studies have suggested potential benefits of TXA:

• A 2021 meta-analysis of 13 randomized controlled trials suggested TXA reduced continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 3
• A 2003 small non-randomized pilot study in dialysis patients suggested TXA may decrease early re-bleeding rates and need for blood transfusions 4

However, these findings are contradicted by more recent, larger, and higher-quality evidence that found:

• No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1
• No significant reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 1
• No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1

Recommended Management Approach for Upper GI Bleeding

Instead of TXA, focus on evidence-based approaches:

1. Resuscitation and hemodynamic stabilization
2. Early endoscopic intervention
3. Vasoactive medications for suspected variceal bleeding 1
4. For variceal bleeding specifically:
   • Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy
   • Antibiotics
   • Endoscopic band ligation 2

Special Considerations

• In trauma patients with bleeding, TXA has proven benefits when administered within 3 hours of injury 2, but this does not extend to GI bleeding
• For patients with liver disease, the risk of thromboembolic events with TXA is particularly elevated 1
• The ineffectiveness of TXA in variceal bleeding may be due to the limited role of hemostasis in this condition and the frequent occurrence of hypofibrinolytic states in critically ill cirrhotic patients 2

In conclusion, current high-quality evidence does not support the use of TXA for upper GI bleeding and suggests potential harm, particularly in patients with liver disease.