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

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed, particularly in patients with cirrhosis and active variceal bleeding, due to the lack of beneficial effect and potential increased risk of venous thromboembolic events 1. When considering the use of TXA in GI bleeding, it's essential to differentiate between upper and lower GI bleeds, as well as the underlying cause of the bleed.

• For upper GI bleeds, TXA may be considered as an adjunct therapy, but its use should be cautious and based on individual patient assessment.
• The evidence from the HALT-IT trial, as mentioned in the British Society of Gastroenterology guidelines 1, suggests that TXA may have a benefit in acute GI bleeding, but this benefit is not apparent when limited to trials at low risk of bias. However, the most recent and highest quality study 1 recommends against the use of TXA in patients with cirrhosis and active variceal bleeding, citing a lack of beneficial effect and a potential increased risk of venous thromboembolic events. Key points to consider when evaluating the use of TXA in GI bleeding include:
• The underlying cause of the bleed, such as variceal bleeding or non-variceal bleeding
• The presence of cirrhosis or other underlying liver disease
• The risk of thromboembolic events, particularly in patients with a history of thromboembolism or severe renal impairment
• The potential benefits and risks of TXA in individual patients, weighing the lack of beneficial effect against the potential increased risk of adverse events.

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.