What is the role of tranexamic acid (TXA) in the management of upper gastrointestinal bleeding (UGIB)?

Tranexamic Acid in Upper Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for routine use in the management of upper gastrointestinal bleeding (UGIB) due to lack of mortality benefit and increased risk of thromboembolic events. 1

Current Evidence and Recommendations

Guidelines on TXA Use in UGIB

The most recent guidelines from the European Association for the Study of the Liver (EASL) and the European Society of Intensive Care Medicine specifically recommend against the routine use of TXA in patients with gastrointestinal bleeding 1. This recommendation is based on high-certainty evidence showing:

• No reduction in mortality with high-dose IV TXA
• Increased risks of adverse events including:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72)
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0)
  • Seizures (RR 1.73,95% CI 1.03-2.93)

While older meta-analyses suggested potential benefits, the most recent and comprehensive evidence does not support routine TXA use in UGIB management.

Conflicting Evidence in Research Studies

Some research studies have shown potential benefits of TXA in UGIB:

• A 2021 meta-analysis found TXA significantly reduced continued bleeding (RR = 0.60), need for urgent endoscopic intervention (RR = 0.35), and mortality (RR = 0.60) compared to placebo 2
• Another 2021 systematic review found TXA decreased risk of rebleeding (RR = 0.64) and need for surgery (RR = 0.59) but did not show a statistically significant effect on mortality 3

However, these findings conflict with the more recent guideline recommendations, which are based on higher-quality evidence and more comprehensive analysis of risks and benefits.

Management Algorithm for UGIB

Instead of TXA, the recommended approach for UGIB includes:

1. Resuscitation and hemodynamic stabilization:

   • Target hemoglobin level of 70-90 g/L
   • Restrictive packed red blood cell transfusion strategy (transfuse when Hb <7 g/dl with target 7-9 g/dl) 1

2. Early endoscopic intervention:

   • Prompt endoscopy for diagnosis and treatment
   • Endoscopic therapy for active bleeding or high-risk stigmata

3. Pharmacological management:

   • High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hr infusion for 72 hours) following successful endoscopic therapy 4
   • Vasoactive medications for variceal bleeding

4. Management of rebleeding:

   • Repeat endoscopy to confirm rebleeding and attempt endoscopic therapy once more 4
   • Consider surgical intervention if endoscopic therapy fails

Special Considerations

Portal Hypertension-Related Bleeding

For patients with cirrhosis and portal hypertension-related bleeding, portal hypertension-lowering measures are recommended rather than TXA 1.

Dialysis Patients

A small non-randomized study suggested potential benefit of TXA in dialysis patients with UGIB 5, but this finding requires confirmation in larger randomized trials and is insufficient to override guideline recommendations.

Conclusion

While some research suggests TXA may reduce rebleeding and need for surgery in UGIB, current high-quality guidelines recommend against its routine use due to lack of mortality benefit and increased risk of thromboembolic complications. The cornerstone of UGIB management remains prompt resuscitation, early endoscopic intervention, and appropriate pharmacological therapy with proton pump inhibitors.