From the Guidelines
Tranexamic acid (TXA) should not be used to stop gastrointestinal (GI) bleeding, particularly in patients with cirrhosis and active variceal bleeding, due to the lack of benefit and potential increased risk of venous thromboembolic events 1. The use of TXA in GI bleeding has been evaluated in several studies, with mixed results. A 2019 guideline from the British Society of Gastroenterology suggested that TXA may be beneficial in acute GI bleeding, with a 40% risk reduction in mortality 1. However, this benefit was not apparent when the analysis was limited to trials at low risk of bias, and the studies were considered historic and not representative of modern day care. In contrast, a more recent study published in 2022 in the Journal of Hepatology found that TXA did not reduce mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, and was associated with an increased risk of venous thromboembolic events 1. This study included a large number of patients and had a high level of evidence, making its findings more reliable. Key points to consider when evaluating the use of TXA in GI bleeding include:
- The underlying cause of the bleeding, such as variceal bleeding or peptic ulcer disease
- The presence of cirrhosis or other liver disease
- The risk of venous thromboembolic events
- The potential benefits and harms of TXA in different patient populations In general, the primary management of GI bleeding should focus on identifying and treating the underlying cause, such as endoscopic intervention for bleeding ulcers, along with acid suppression therapy with proton pump inhibitors. TXA should only be considered as an adjunctive therapy in specific cases, and its use should be carefully weighed against the potential risks and benefits.
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.