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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended for stopping upper GI bleeding and may increase the risk of thromboembolic events, particularly in patients with liver disease. 1

Current Guidelines on TXA for Upper GI Bleeding

The European Association for the Study of the Liver (EASL) and British Society of Gastroenterology (BSG) provide clear guidance:

• EASL strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1
• BSG suggests that TXA use in acute GI bleeding should be confined to clinical trials only 1
• A large randomized placebo-controlled trial with 12,009 patients showed an almost 2-fold increase in venous thromboembolic events in the TXA group 1

Why TXA Is Ineffective for Upper GI Bleeding

TXA's mechanism of action doesn't align with the pathophysiology of upper GI bleeding:

• Limited role of fibrinolysis in variceal bleeding mechanisms 1
• Patients with cirrhosis often have a hypofibrinolytic state, making antifibrinolytics unnecessary or potentially harmful 1
• Risk of thrombotic complications appears particularly elevated in patients with liver disease 1

Conflicting Evidence

Despite the strong recommendations against TXA in guidelines, some research suggests potential benefits:

• A 2021 meta-analysis of 13 randomized controlled trials (n=2271) found that TXA significantly reduced continued bleeding (RR=0.60), urgent endoscopic intervention (RR=0.35), and mortality (RR=0.60) compared to placebo 2
• A small 2003 study in dialysis patients with upper GI bleeding suggested benefits of TXA in decreasing early re-bleeding rates and blood transfusion requirements 3

However, these studies have important limitations:

• Many were conducted before modern endoscopic techniques and PPI therapy became standard
• Most did not include patients with liver disease, where risks appear highest
• Sample sizes were generally small compared to more recent negative studies

Recommended Management for Upper GI Bleeding

For Variceal Bleeding

1. Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 1
2. Prophylactic antibiotics 1
3. Endoscopic band ligation (EBL) 1
4. Restrictive red blood cell transfusion strategy 1

For Non-Variceal Upper GI Bleeding

1. High-dose proton pump inhibitors (80 mg stat followed by an infusion of 8 mg hourly for 72 hours) following successful endoscopic therapy 1
2. Endoscopic therapy as the primary intervention 1
3. Restrictive transfusion strategy 1

Important Caveats

• The American Association for the Study of Liver Diseases (AASLD) states that prophylactic use of TXA to prevent procedural bleeding cannot be recommended until further supportive data are published 1
• Patients with liver disease appear to be at particularly high risk for thrombotic complications with TXA 1
• The HALT-IT trial, one of the largest studies on this topic, was designed to provide definitive evidence on TXA in GI bleeding 4

In summary, current guidelines strongly recommend against using TXA for upper GI bleeding, particularly in patients with liver disease, due to increased risk of thromboembolic events and lack of proven efficacy. Standard management with vasoactive drugs, endoscopic therapy, and PPIs remains the recommended approach.