Is tranexamic acid (TXA) used to treat bleeding peptic ulcer disease (BPUD)?

Tranexamic Acid for Bleeding Peptic Ulcer Disease

Tranexamic acid should NOT be used for bleeding peptic ulcer disease, as high-dose IV TXA provides no mortality or rebleeding benefit while increasing thromboembolic risk, and current guidelines explicitly recommend against its use in gastrointestinal bleeding. 1, 2

Evidence Against TXA Use

High-Dose IV TXA - Clear Harm Without Benefit

• The HALT-IT trial (high-certainty evidence) demonstrated that high-dose intravenous tranexamic acid shows no reduction in mortality (RR 0.98,95% CI 0.88-1.09) or rebleeding rates (RR 0.92,95% CI 0.82-1.04) in gastrointestinal bleeding 1
• The American College of Gastroenterology explicitly does not recommend high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 1
• High-dose TXA increases the risk of thromboembolic events, making the harm-benefit ratio unfavorable 1

Guideline Recommendations

• The British Society of Gastroenterology recommends that TXA use in acute GI bleeding should be confined to clinical trials only 2
• Historical studies showing potential benefit were conducted before modern standard care (high-dose PPIs and endoscopic therapy), making their results not applicable to current practice 2
• Earlier meta-analyses suggesting a 40% mortality reduction lost this treatment benefit when limited to trials with low risk of bias 2

Clinical Reality and Practice Patterns

Declining Use Reflects Evidence

• Observational data from 2010-2013 showed TXA prescription declining over time, with 65% of use occurring in 2010-2011 versus only 35% in 2012-2013 3
• When TXA was used, it was given to patients with more severe bleeding (84% needed transfusion vs 64% in controls), yet these patients had longer hospital stays (5 vs 3 days) and no significant reduction in rebleeding 3
• A Swedish cohort study concluded: "It is time to quit with TXA treatment in all patients with gastrointestinal bleeding, even those at intensive care unit" 4

Thromboembolic Risk Considerations

• TXA carries a documented thrombotic risk, with case reports of recurrent pulmonary embolism associated with its use 5
• The harm-benefit balance is unfavorable when bleeding is not life-threatening, as the thrombotic risk is inadequately evaluated in non-severe bleeding scenarios 6
• Women taking tranexamic acid had a 3-fold higher risk of deep vein thrombosis in observational studies 6

What About Low-Dose TXA?

• Evidence for low-dose IV or enteral TXA shows only moderate certainty and potential benefits (RR 0.5 for rebleeding), but this is not sufficient to recommend routine use 1
• Current evidence does not support routine use of TXA for refractory non-variceal bleeding, and further research is needed before considering low-dose TXA as rescue therapy 1

Standard Management Instead

• For bleeding peptic ulcer disease, prioritize standard management: resuscitation with restrictive transfusion strategy (target hemoglobin 7-9 g/dL), high-dose PPIs, and endoscopic therapy 1
• Standard therapy with endoscopic intervention and pharmacological treatments should be the mainstay, not TXA 1, 2