Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed, especially in patients with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, and actually increased the risk of venous thromboembolic events. This study included a large randomized controlled trial of 12,009 patients, which provides strong evidence against the use of TXA in this context.

When considering the use of TXA in GI bleeding, it's essential to weigh the potential benefits against the risks. While TXA may be effective in reducing mortality in certain types of upper GI bleeds, its use is not recommended in patients with cirrhosis and variceal bleeding due to the increased risk of thrombotic events. Instead, standard treatments such as proton pump inhibitors, endoscopic interventions, and correction of coagulopathies should be prioritized.

In patients with cirrhosis and active bleeding related to portal hypertension, but not to varices, the use of TXA is not indicated, and correction of coagulopathy should be considered on a case-by-case basis. The 2019 guidelines from the British Society of Gastroenterology 1 suggest that TXA may be beneficial in acute GI bleeding, but this recommendation is based on older studies and has been superseded by more recent evidence.

Key points to consider when managing GI bleeding include:

• TXA is not recommended for patients with cirrhosis and variceal bleeding
• Standard treatments such as proton pump inhibitors and endoscopic interventions should be prioritized
• Correction of coagulopathy should be considered on a case-by-case basis
• TXA may be effective in reducing mortality in certain types of upper GI bleeds, but its use should be cautious and based on individual patient risk factors.

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.