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 increased risk of venous thromboembolic events 1.
Mechanism of Action
TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites in the GI tract. However, in the context of variceal bleeding, the limited role of haemostasis and the frequent occurrence of a hypofibrinolytic state in critically ill patients with cirrhosis may render TXA ineffective 1.
Clinical Evidence
A large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA in stopping the bleed, and instead, observed an almost 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group 1.
Treatment Recommendations
For patients with cirrhosis and active variceal bleeding, standard therapy includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, but TXA should not be used 1. In patients with cirrhosis and active bleeding related to portal hypertension, but not to varices, correction of coagulopathy may be considered on a case-by-case basis, but TXA is not recommended 1.
Important Considerations
TXA should be used cautiously in patients with thromboembolic risk factors, and treatment should be monitored for potential side effects including nausea, vomiting, and rarely, thromboembolic events. The underlying cause of the GI bleed should be addressed with specific treatment depending on the etiology, such as peptic ulcers, varices, or other conditions.
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.