From the Guidelines
Tranexamic acid (TXA) should not be used as a first-line treatment to stop gastrointestinal (GI) bleeding, particularly in cases of variceal bleeding, due to the lack of benefit and potential increased risk of thromboembolic events. TXA works by inhibiting the breakdown of blood clots, which can reduce bleeding in some cases, but its effectiveness is limited to certain types of bleeding, such as mucosal bleeding, and not recommended for variceal bleeding 1. For upper GI bleeding, the primary treatments usually include endoscopic interventions, proton pump inhibitors, and addressing the underlying cause. TXA may be considered as an adjunctive treatment in specific cases, but its use should be cautious and based on individual patient assessment, taking into account the potential risks and benefits, as suggested by the British Society of Gastroenterology guidelines 1.
Some key points to consider when evaluating the use of TXA in GI bleeding include:
- The lack of benefit of TXA in variceal bleeding, as shown in a large randomized placebo-controlled trial 1
- The potential increased risk of thromboembolic events associated with TXA use, particularly in patients with comorbid liver disease or suspected variceal bleeding 1
- The importance of individual patient assessment and cautious use of TXA, considering the potential risks and benefits 1
- The primary treatments for GI bleeding, including endoscopic interventions, proton pump inhibitors, and addressing the underlying cause, which should be prioritized over TXA use.
In terms of specific patient populations, such as those with cirrhosis, the use of TXA is not recommended due to the lack of benefit and potential increased risk of thromboembolic events 1. Instead, treatment should focus on standard therapies, including vasoactive therapy, antibiotics, and endoscopic treatment, as well as addressing the underlying cause of bleeding.
From the Research
Efficacy of Tranexamic Acid in GI Bleeding
- Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with mixed results 2, 3, 4, 5, 6.
- A 2021 systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 2.
- Another study published in 2022 found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 3.
- A 2024 meta-analysis found that TXA with acid suppression significantly reduced the risk of rebleeding, units of blood transfused, and the need for salvage therapy in patients with upper GI bleeding 4.
- However, a 2020 systematic review and meta-analysis found that TXA did not improve outcomes in upper GI bleeding and may increase the risk of venous thromboembolic events 5.
- A 2025 comprehensive systematic review and meta-analysis found that TXA significantly reduced rebleeding rates, particularly in upper GI bleeding, and was associated with a mortality reduction when administered through both oral and intravenous routes 6.
Safety and Adverse Events
- The use of TXA in GI bleeding has been associated with an increased risk of thromboembolic events, including deep venous thrombosis and pulmonary embolism 3, 5.
- However, a 2025 meta-analysis found that there was no definitive evidence that TXA use is associated with thromboembolic events 6.
- The safety and efficacy of TXA in lower GI bleeding are less clear, with one study finding that TXA was linked to a significant increase in mortality in patients with lower GI bleeding 6.
Clinical Implications
- The available evidence suggests that TXA may be a useful adjunctive treatment for upper GI bleeding, particularly when combined with acid suppression 2, 4, 6.
- However, the use of TXA in GI bleeding should be approached with caution, taking into account the potential risks and benefits, as well as individual patient factors 3, 5, 6.