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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) may reduce the need for surgical intervention and mortality in upper GI bleeding, but it is not currently recommended as routine therapy due to insufficient evidence. 1

Efficacy of TXA in Upper GI Bleeding

• Meta-analyses have shown that tranexamic acid therapy, while not reducing ulcer rebleeding, appears to reduce the need for surgical intervention and tends to reduce mortality in ulcer bleeding patients. 1
• However, these meta-analyses were likely skewed by inclusion of extremely large trials with unusually high mortality in control groups. 1
• Current guidelines do not recommend TXA as routine therapy for upper GI bleeding, stating that further studies are necessary before it can be recommended. 1

Evidence from Recent Research

• A 2021 meta-analysis found that TXA significantly reduced the rates of continued bleeding (RR = 0.60), urgent endoscopic intervention (RR = 0.35), and mortality (RR = 0.60) compared with placebo in upper GI bleeding. 2
• Another 2021 systematic review showed that TXA decreased the risk of rebleeding (RR = 0.64) and need for surgery (RR = 0.59), but did not find a statistically significant effect on mortality (RR = 0.95) or thromboembolic events (RR = 0.93). 3
• A Cochrane review found that TXA appears to have a beneficial effect on mortality, but high dropout rates in some trials limited confidence in these findings. 4

Current Recommended Management for Upper GI Bleeding

• Endoscopic therapy remains the first-line treatment for actively bleeding ulcers with high-risk stigmata. 1
• Following successful endoscopic therapy, high-dose proton pump inhibitor therapy (80 mg stat followed by an infusion of 8 mg hourly for 72 hours) is recommended. 1
• H2-receptor antagonists are not recommended in the management of patients with acute upper GI bleeding. 1
• Somatostatin and octreotide are not recommended in the routine management of patients with acute nonvariceal upper GI bleeding. 1

Considerations for TXA Use

• TXA works by inhibiting the breakdown of fibrin clots by plasmin, which may help stabilize clots in bleeding situations. 5
• The safety profile of TXA regarding thromboembolic events remains unclear, with most studies being underpowered to detect differences in these relatively rare events. 3, 4
• For patients with advanced malignancy and bleeding, TXA may be considered as part of a pragmatic approach, although this carries an increased risk of thrombosis. 1

Conclusion for Clinical Practice

• While TXA shows promise in reducing surgical intervention and possibly mortality in upper GI bleeding, current guidelines do not recommend its routine use. 1
• The standard of care for upper GI bleeding remains prompt endoscopic evaluation and therapy, followed by high-dose proton pump inhibitor therapy. 1
• For patients with active bleeding that cannot be controlled endoscopically, surgical intervention is indicated rather than relying on pharmacologic therapy alone. 1
• The results of the HALT-IT trial (a large randomized controlled trial with 12,000 patients) will provide more definitive evidence about the role of TXA in GI bleeding. 5