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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) should not be used routinely for upper GI bleeding as it shows no mortality benefit and may increase thrombotic risk, particularly in patients with liver disease. 1

Evidence on TXA in Upper GI Bleeding

Guidelines and High-Quality Evidence

The most recent and highest quality evidence comes from guidelines that specifically address this question:

• The 2022 EASL Clinical Practice Guidelines strongly recommend against using tranexamic acid in patients with cirrhosis and active variceal bleeding (Level of Evidence 2, strong recommendation) 1. This recommendation is based on a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding.

• The British Society of Gastroenterology (2019) suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 1. While some older pooled analyses showed a 40% risk reduction in mortality with TXA in upper GI bleeding, this benefit disappeared when analysis was limited to trials with low risk of bias 1.

Mechanism and Concerns

TXA is an antifibrinolytic agent that inhibits the breakdown of fibrin clots by plasmin. While this mechanism is beneficial in trauma settings, several issues exist with its use in GI bleeding:

• In variceal bleeding (a common cause of upper GI bleeding), haemostasis plays a limited role, and critically ill cirrhotic patients often have a hypofibrinolytic state already 1.

• A large trial showed almost 2-fold increase in venous thromboembolic events with TXA compared to placebo, with risk concentrated in patients with liver disease/suspected variceal bleeding 1.

Special Considerations

Trauma vs. GI Bleeding

While TXA has proven benefits in trauma (CRASH-2 trial) when administered within 3 hours of injury 1, this benefit has not translated to GI bleeding populations.

Recent Research

Some smaller recent studies have shown potential benefits:

• A 2023 randomized trial showed TXA reduced rebleeding (25.6% vs. 46.5%), need for blood transfusion, and hospital stay in upper GI bleeding, but with no effect on mortality 2.
• A 2021 meta-analysis suggested TXA reduced continued bleeding, need for urgent endoscopic intervention, and mortality compared to placebo 3.

However, these smaller studies are outweighed by the large-scale evidence cited in current guidelines.

Clinical Approach to Upper GI Bleeding

Instead of TXA, the recommended approach includes:

1. Prompt initiation of vasoactive therapy (terlipressin, somatostatin or octreotide) before endoscopy
2. Antibiotic therapy
3. Endoscopic band ligation for variceal bleeding
4. Restrictive red blood cell transfusion strategy
5. Careful consideration of coagulation correction on a case-by-case basis

Pitfalls and Caveats

• Don't use TXA in patients with suspected variceal bleeding or liver disease due to increased thrombotic risk
• Don't assume that TXA's benefits in trauma settings translate to GI bleeding
• Don't delay standard treatments (endoscopy, vasoactive drugs) while considering TXA
• Be aware that administration of large volumes of blood products may paradoxically increase bleeding in cirrhotic patients by raising portal pressure 1

In conclusion, while TXA continues to be studied in GI bleeding, current high-quality evidence does not support its routine use for upper GI bleeding, particularly in patients with liver disease or suspected variceal bleeding.