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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not recommended for routine use in upper GI bleeding as there is insufficient evidence to support its effectiveness in stopping upper GI bleeds compared to standard treatments. 1

Current Evidence on TXA for Upper GI Bleeding

Guideline Recommendations

• The 2019 international consensus guidelines for management of nonvariceal upper GI bleeding do not include tranexamic acid in their recommended treatment algorithm 1
• The 2002 Gut guidelines specifically state that "further studies of tranexamic acid are necessary before it can be recommended as routine therapy" 1
• Current guidelines prioritize other interventions for upper GI bleeding:
  • Early endoscopy (within 24 hours of presentation) 1
  • Endoscopic hemostatic therapy for high-risk stigmata 1
  • Proton pump inhibitor therapy following successful endoscopic therapy 1

Evidence on TXA Efficacy

• Meta-analyses have shown mixed results:
  • Some evidence suggests TXA may reduce mortality in upper GI bleeding (RR: 0.61,95% CI: 0.42-0.89) 2, 3
  • However, these findings were not confirmed when accounting for bias control or in sequential analyses 3
  • No significant differences were found between TXA and placebo on bleeding control, need for surgery, or transfusion requirements 2, 3
  • Most studies were conducted before the routine use of modern endoscopic therapy and high-dose acid suppression 1

Safety Concerns

• There are concerns about potential thromboembolic events with TXA use 3
• Five cases of serious thromboembolic events (myocardial infarction, pulmonary embolism, and cerebral infarction) were reported in TXA groups in clinical trials 3

Recommended Management Approach for Upper GI Bleeding

First-Line Interventions

• Early endoscopy (within 24 hours) for diagnosis and therapeutic intervention 1
• Endoscopic hemostatic therapy for high-risk lesions:
  • Thermocoagulation or sclerosant injection for actively bleeding ulcers 1
  • Through-the-scope clips for actively bleeding ulcers 1
  • Epinephrine injection should not be used alone but in combination with another method 1

Pharmacological Management

• Proton pump inhibitor therapy via intravenous loading dose followed by continuous infusion after successful endoscopic therapy 1
• H2-receptor antagonists are not recommended 1
• Somatostatin and octreotide are not routinely recommended 1

Special Circumstances

In specific situations, TXA might be considered:

• For patients with bleeding tumors in advanced malignancy, TXA may be used as a pragmatic approach, though it carries an increased risk of thrombosis 1
• In patients who refuse blood products (e.g., Jehovah's Witnesses) or when standard treatments are unavailable 4
• As a temporizing measure while awaiting definitive endoscopic therapy in severe, life-threatening bleeding 5

Conclusion

While some evidence suggests TXA may reduce mortality in upper GI bleeding, current guidelines do not recommend its routine use due to methodological limitations in existing studies and the availability of more effective treatments. The primary approach to upper GI bleeding should focus on early endoscopy with appropriate hemostatic techniques and proton pump inhibitor therapy.