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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended as a routine treatment for upper GI bleeding as it does not reduce rebleeding rates, and evidence for its mortality benefit is inconsistent and of low quality. 1

Current Evidence on TXA for Upper GI Bleeding

Guideline Recommendations

The most recent guidelines on gastrointestinal bleeding indicate that:

• Tranexamic acid has shown some evidence of reducing mortality and surgical intervention in older meta-analyses, but these benefits disappear when analysis is limited to trials with low risk of bias 1
• The evidence supporting TXA use is considered historic and predates routine use of high-dose acid suppression and modern endoscopic therapy 1
• Current guidelines suggest that TXA use should be confined to clinical trials rather than routine clinical practice 1

First-Line Treatments for Upper GI Bleeding

Instead of TXA, the following treatments are recommended:

1. Endoscopic therapy: The cornerstone of management for high-risk stigmata (active bleeding or visible vessel) 1

   • Combination therapy with epinephrine injection plus another method (thermocoagulation or clips) is superior to epinephrine alone 1

2. Proton Pump Inhibitors (PPIs):

   • High-dose PPI therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) is strongly recommended following successful endoscopic therapy 1
   • This approach reduces rebleeding rates, blood transfusion requirements, and hospital stay 1

Potential Role of TXA in Specific Situations

While not recommended as routine therapy, TXA might be considered in specific circumstances:

• When conventional endoscopic therapies are not available or have failed 1
• In patients awaiting definitive treatment (as a temporizing measure) 2
• In dialysis patients with major upper GI bleeding, where a small non-randomized study showed benefits in reducing rebleeding and transfusion requirements 3

Safety Considerations

• Thromboembolic risk: Available data from older trials suggest TXA does not significantly increase thromboembolic disease risk 4
• Studies have been too small to adequately assess thromboembolic events in GI bleeding 1

Management Algorithm for Upper GI Bleeding

1. Initial resuscitation and risk assessment

   • Fluid resuscitation
   • Blood transfusion if hemoglobin <70-90 g/L

2. First-line treatment:

   • Early endoscopy (within 24 hours)
   • Endoscopic therapy for high-risk stigmata
   • High-dose PPI therapy following endoscopy

3. For refractory bleeding:

   • Repeat endoscopic therapy (one attempt)
   • Consider interventional radiology or surgery if bleeding persists

4. Consider TXA only if:

   • Participating in a clinical trial
   • Conventional therapies have failed or are unavailable
   • As a temporizing measure while awaiting definitive treatment

Pitfalls and Caveats

• Relying on TXA alone without pursuing definitive endoscopic therapy may delay appropriate treatment
• The HALT-IT trial results (pending at the time of these guidelines) were expected to provide more definitive evidence on TXA in GI bleeding 5
• Most evidence for TXA comes from studies conducted before modern endoscopic techniques and PPI therapy were widely available 1

In summary, while some evidence suggests TXA may reduce mortality in upper GI bleeding, current guidelines do not support its routine use outside clinical trials. Endoscopic therapy combined with high-dose PPI remains the standard of care.