Topical Hemostatic Therapies for Nonvariceal GI Bleeding

This review focused on evaluating the efficacy of four topical hemostatic agents—Hemospray, Nexpowder, EndoClot, and PuraStat—approved in the U.S. for treating nonvariceal gastrointestinal bleeding (GIB). The author aimed to assess whether these newer agents are superior or comparable to conventional endoscopic therapies based on randomized controlled trial evidence.

Nonvariceal GIB is a potentially life-threatening condition requiring prompt treatment to stop bleeding and prevent recurrence. While conventional endoscopic therapies are effective, newer topical agents may offer potential benefits, such as ease of application or use in challenging cases like malignant bleeding. Evaluating these agents helps refine treatment decisions and guide clinicians in choosing the most effective and cost-efficient therapies.

The author conducted a literature review of randomized controlled trials (RCTs), focusing on studies that compared topical agents with conventional endoscopic therapies. Fully published trials evaluating clinically important outcomes such as further bleeding (persistent or recurrent bleeding) were included. Observational studies were excluded due to their limitations in assessing efficacy.

Hemospray demonstrated noninferiority to conventional therapies in preventing further bleeding and showed better initial hemostasis rates, especially for malignancy-related bleeding. Nexpowder reduced recurrent bleeding when applied after achieving hemostasis with conventional therapies but lacks data as a primary treatment. EndoClot appeared to show efficacy, but with a somewhat low initial hemostasis rate of 73% for active bleeding, although study limitations, such as concurrent epinephrine use and reporting of outcomes, complicate interpretation. PuraStat lacks RCT data for acute GIB but has been evaluated for procedural bleeding, showing no reduction in delayed bleeding after procedures like endoscopic submucosal dissection.

Hemospray is the most validated option among the topical hemostatic agents for initial treatment of nonvariceal GIB, particularly for active bleeding and malignancy-related cases. However, its higher cost and potential technical challenges, such as catheter clogging, may limit its use. Nexpowder appears useful for reduction of rebleeding after conventional therapy. Nexpowder, EndoClot, and PuraStat require additional RCTs to better determine their roles as initial primary therapy in managing acute GIB.

The author emphasized the need for additional large, well-designed RCTs to evaluate Nexpowder, EndoClot, and PuraStat as primary therapies for acute GIB. Ongoing trials comparing Nexpowder and PuraStat with conventional therapies will provide critical insights into their clinical utility.