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 venous 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 12,009 patients, nearly 50% of whom had suspected variceal bleeding, and found no beneficial effect of TXA in the whole group or in the subgroup analysis of patients with suspected variceal bleeding and liver disease comorbidity.
The mechanism of action of TXA involves inhibiting fibrinolysis, which may not be effective in variceal bleeding due to the limited role of haemostasis in this type of bleeding. Additionally, patients with cirrhosis and acute-on-chronic liver failure may be in a hypofibrinolytic state, which could further reduce the effectiveness of TXA. The study also found that the risk of venous thromboembolic events was concentrated in patients with comorbid liver disease/suspected variceal bleeding, highlighting the potential harm of using TXA in these patients.
In contrast to the potential benefits of TXA in upper GI bleeds, the evidence suggests that TXA is not effective in stopping GI bleeds, particularly in patients with cirrhosis and variceal bleeding. The 2019 guidelines from the British Society of Gastroenterology 1 suggested that TXA may be beneficial in acute GI bleeding, but this was based on older studies with limited evidence. The more recent and higher quality study published in 2022 1 supersedes this evidence and provides a stronger recommendation against the use of TXA in patients with cirrhosis and active variceal bleeding.
Some key points to consider when managing GI bleeds include:
- The use of vasoactive therapy, antibiotics, and endoscopic treatment as standard therapy for variceal bleeding
- The potential harm of administering large volumes of blood products, which may increase portal pressure and worsen outcomes
- The importance of individualizing treatment decisions based on the underlying cause and location of the bleed, as well as the patient's underlying medical conditions and 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.