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

Tranexamic Acid for Upper GI Bleeding

Tranexamic acid (TXA) is not currently recommended as routine therapy for upper GI bleeding, as current guidelines suggest further studies are necessary before it can be recommended for standard practice. 1

Efficacy of TXA in Upper GI Bleeding

• Meta-analyses suggest TXA may reduce the need for surgical intervention and tends to reduce mortality in ulcer bleeding patients, but the evidence is not strong enough for routine recommendation 1
• Recent research indicates TXA significantly reduces continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared to placebo 2
• A 2023 randomized clinical trial found TXA was associated with lower rates of rebleeding (25.6% vs 46.5%, p=0.043) and reduced need for blood transfusion (7% vs 32.6%, p=0.003) in patients with massive upper GI bleeding 3

Current Standard 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 is recommended 1
• For patients with active bleeding that cannot be controlled endoscopically, surgical intervention is indicated rather than relying on pharmacologic therapy alone 1

Limitations of Current Evidence

• Many studies on TXA for GI bleeding are considered historic and were conducted before the routine use of high-dose acid suppression and modern endoscopic therapy 4
• The British Society of Gastroenterology suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 4
• Studies have been too small to adequately assess the effect of tranexamic acid on thromboembolic events in the context of GI bleeding 4

Practical Considerations for TXA Use

• When TXA is used in trauma settings, it should be administered as soon as possible, with a loading dose of 1g over 10 minutes, followed by an intravenous infusion of 1g over 8 hours 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
• TXA appears to have a favorable safety profile with no significant increase in thromboembolic events reported in most studies 5, 3

Clinical Algorithm for Upper GI Bleeding Management

1. First-line: Prompt endoscopic evaluation and therapy 1
2. Second-line: High-dose proton pump inhibitor therapy following endoscopy 1
3. For refractory bleeding: Consider surgical or interventional radiology approaches 1
4. TXA consideration: May be considered in specific scenarios where standard treatments are unavailable or delayed, or in patients with massive bleeding awaiting definitive intervention 3

Dosing if TXA is Used

• Loading dose: 1g IV over 10 minutes 4
• Maintenance: 1g IV over 8 hours 4, 6
• Administration should ideally be within 3 hours of bleeding onset for maximum benefit 4

While TXA shows promise in reducing rebleeding and possibly mortality in upper GI bleeding, the current standard of care remains prompt endoscopic evaluation and therapy, followed by high-dose proton pump inhibitor therapy.