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, as current evidence does not support its routine use in managing upper GI bleeds 1.

Key Points

• The standard treatment approach for upper GI bleeding includes proton pump inhibitors, endoscopic therapy to directly treat the bleeding source, and supportive care including fluid resuscitation and blood transfusions as needed.
• TXA works by inhibiting fibrinolysis and stabilizing blood clots, which theoretically could help control bleeding, but multiple clinical trials and meta-analyses have failed to demonstrate a significant mortality benefit or reduction in rebleeding rates when TXA is added to standard therapy for upper GI bleeds.
• A large randomised placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of tranexamic acid in the whole group nor in the subgroup analysis of patients with suspected variceal bleeding and liver disease comorbidity 1.
• The use of TXA may also increase the risk of venous thromboembolic events, particularly in patients with comorbid liver disease or suspected variceal bleeding 1.

Recommendations

• Focus on rapid assessment, hemodynamic stabilization, early endoscopy, and appropriate acid suppression therapy when managing an upper GI bleed.
• Consider the use of viscoelastic tests to guide transfusion and reduce blood product use in patients with cirrhosis and active upper gastrointestinal bleeds 1.
• Use portal hypertension-lowering measures to manage bleeding related to portal hypertension, but not to varices, and consider correction of haemostasis on a case-by-case basis in case of failure to control haemorrhage 1.

From the Research

Effectiveness of Tranexamic Acid in Upper GI Bleed

• Tranexamic acid (TXA) has been studied for its potential to stop upper gastrointestinal (GI) bleeding, with evidence suggesting it may be effective in reducing hemorrhage and mortality 2, 3, 4, 5, 6.
• A systematic review and meta-analysis of randomized clinical trials found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality compared to placebo 2.
• Another study found that TXA may reduce all-cause mortality, but the evidence was limited by the internal and external validity of the included trials 3.
• A Cochrane review found that TXA reduced mortality compared to placebo, but the beneficial effect was not confirmed in subgroup analysis or sensitivity analyses 4.
• TXA has been suggested as an adjuvant treatment for upper GI bleeding, but its use should be carefully evaluated due to the risk of thromboembolic events, particularly in older patients with co-morbidities 5.
• A meta-analysis of systematic reviews found that TXA probably decreases rebleeding and mortality without increasing thromboembolic adverse effects in patients with upper GI bleeding 6.

Key Findings

• TXA may reduce hemorrhage and mortality in upper GI bleeding 2, 3, 4, 6.
• The evidence for TXA's effectiveness is limited by the quality of the included trials and the risk of thromboembolic events 3, 4, 5.
• Further studies are needed to confirm the benefits and risks of TXA in upper GI bleeding 2, 3, 4, 5, 6.