Tranexamic Acid for Upper GI Bleeding: Evidence and Recommendations
Tranexamic acid (TXA) is not recommended for routine use in upper GI bleeding as it does not reduce mortality and may increase thrombotic risk, while other interventions like proton pump inhibitors and endoscopic therapy have proven more effective.
Current Evidence on TXA for Upper GI Bleeding
Guideline Recommendations
The British Society of Gastroenterology (BSG) states that "tranexamic acid therapy, while not reducing ulcer rebleeding, does appear to reduce the need for surgical intervention and tends to reduce mortality in ulcer bleeding patients." However, they conclude that "further studies of tranexamic acid are necessary before it can be recommended as routine therapy" 1.
The European Association for the Study of the Liver (EASL) strongly recommends against using tranexamic acid in patients with acute upper gastrointestinal bleeding, noting an almost 2-fold increase in venous thromboembolic events in the TXA group 2.
The BSG suggests that tranexamic acid use in acute GI bleeding should be confined to clinical trials 2.
Meta-analyses and Research
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 with placebo 3.
A 2021 systematic review found that TXA decreased the risk of rebleeding (RR=0.64) and need for surgery (RR=0.59), but did not show statistically significant effects on mortality (RR=0.95) or thromboembolic events (RR=0.93) 4.
Recommended First-Line Treatments for Upper GI Bleeding
Endoscopic Therapy
- Endoscopic hemostatic therapy is the primary recommended intervention for patients with high-risk stigmata (active bleeding or a visible vessel in an ulcer bed) 1.
Pharmacologic Management
High-dose proton pump inhibitor therapy (80 mg stat followed by an infusion of 8 mg hourly for 72 hours) is strongly recommended following successful endoscopic therapy 1.
H2-receptor antagonists are not recommended for patients with acute ulcer bleeding 1.
Somatostatin and octreotide are not routinely recommended for patients with acute ulcer bleeding 1.
When TXA Might Be Considered
Despite not being recommended for routine use, TXA might be considered in specific circumstances:
As a temporizing measure in patients with ongoing bleeding who are awaiting definitive intervention 1.
In patients who refuse blood products (e.g., Jehovah's Witnesses) 5.
Algorithm for Managing Upper GI Bleeding
Initial resuscitation and stabilization
- IV fluid resuscitation
- Blood transfusion if hemoglobin < 70 g/L
Early endoscopy (within 24 hours of presentation)
- Identify bleeding source
- Apply appropriate endoscopic therapy for high-risk stigmata
Pharmacologic therapy
- Start high-dose PPI therapy (80 mg IV bolus followed by 8 mg/hr infusion for 72 hours)
- Do not use H2-receptor antagonists or somatostatin/octreotide
For rebleeding
- Consider repeat endoscopic therapy
- If endoscopic therapy fails, consider interventional radiology or surgery
TXA consideration
- Not for routine use
- May be considered in special circumstances (e.g., patients refusing blood products)
- Be aware of increased thrombotic risk, particularly in patients with liver disease
Pitfalls and Caveats
TXA appears to have limited effectiveness in upper GI bleeding due to the limited role of fibrinolysis in these bleeding mechanisms 2.
The risk of thrombotic complications with TXA appears to be particularly elevated in patients with liver disease 2.
The apparent benefits of TXA seen in some meta-analyses may be skewed by inclusion of older studies with methodological limitations 1.
Current evidence strongly supports endoscopic therapy and PPI use as the mainstays of treatment for upper GI bleeding, with much stronger evidence than exists for TXA.