Can tranexamic acid (TXA) be used to stop upper gastrointestinal (GI) hemorrhage?

Tranexamic Acid for Upper GI Hemorrhage

Tranexamic acid is not recommended for routine use in upper GI hemorrhage as it does not reduce death from gastrointestinal bleeding and is associated with increased risk of venous thromboembolic events. 1, 2

Evidence Assessment

The most recent and highest quality evidence strongly advises against using tranexamic acid (TXA) for upper GI bleeding:

• The European Association for the Study of the Liver (EASL) strongly recommends against using TXA in patients with active upper GI bleeding, particularly in those with cirrhosis 1
• A large randomized controlled trial (HALT-IT) including 12,009 patients found that TXA did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) 2
• TXA was associated with an almost 2-fold increase in venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) compared to placebo (0.8% vs. 0.4%; RR 1.85,95% CI 1.15-2.98) 1, 2
• The British Society of Gastroenterology (BSG) suggests that TXA use in acute GI bleeding should be confined to clinical trials 1

Reasons for TXA Ineffectiveness in Upper GI Bleeding

• Limited role of fibrinolysis in the mechanisms of upper GI bleeding 1
• Patients with cirrhosis often have a hypofibrinolytic state, making antifibrinolytics unnecessary or potentially harmful 1
• Local administration of TXA has also shown no additional benefit over standard care 3

Recommended Management for Upper GI Bleeding

For Non-Variceal Upper GI Bleeding:

• High-dose proton pump inhibitors (80 mg stat followed by an infusion of 8 mg hourly for 72 hours) following successful endoscopic therapy 4, 1
• Endoscopic therapy as the primary intervention for patients with high-risk stigmata (active bleeding or visible vessel) 4
• A restrictive transfusion strategy 1

For Variceal Bleeding:

• Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 1
• Prophylactic antibiotics 1
• Endoscopic band ligation (EBL) 1
• A restrictive red blood cell transfusion strategy 1

Historical Context and Conflicting Evidence

Earlier and smaller studies had suggested potential benefits of TXA in upper GI bleeding:

• Meta-analyses of small trials suggested TXA might decrease mortality and rebleeding 5, 6
• A 1979 double-blind study showed reduced transfusion requirements with TXA 7

However, these findings have been superseded by the much larger and more recent HALT-IT trial 2, which provides more reliable evidence that TXA does not reduce mortality in GI bleeding and increases thromboembolic risk.

Clinical Pitfalls to Avoid

• Do not use TXA as a routine treatment for upper GI bleeding based on outdated evidence
• Do not delay standard treatments (endoscopy and PPI therapy) while considering TXA
• Be aware of the increased risk of venous thromboembolism with TXA, particularly in patients with liver disease 1
• Remember that other antifibrinolytic drugs have similar limitations - a meta-analysis showed that while TXA therapy appeared to reduce surgical intervention and tended to reduce mortality, it did not reduce ulcer rebleeding 4

Instead, focus on prompt endoscopic intervention and appropriate pharmacological management with proton pump inhibitors for non-variceal bleeding or vasoactive drugs for variceal bleeding.