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 potential increased risk of venous thromboembolic events 1.

Mechanism of Action

TXA works by inhibiting the breakdown of blood clots, helping to stabilize clot formation at the bleeding site. This mechanism is particularly useful in situations where fibrinolysis (clot breakdown) contributes to ongoing bleeding. However, the use of TXA in GI bleeding is not supported by recent evidence, particularly in the context of variceal bleeding.

Recent 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 increased risk of venous thromboembolic events 1. This study suggests that TXA may not be effective in managing GI bleeds, especially in patients with liver disease and suspected variceal bleeding.

Clinical Considerations

In patients with cirrhosis and active bleeding related to portal hypertension, the use of TXA is not recommended 1. Instead, standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment. The correction of haemostatic abnormalities should be considered on a case-by-case basis, and the use of blood products should be done cautiously to avoid increasing portal pressure and worsening outcomes.

Potential Side Effects

Potential side effects of TXA include nausea, vomiting, diarrhea, and a theoretical risk of thromboembolic events, though this risk is generally low in the short-term treatment of acute bleeding. However, the risk of venous thromboembolic events was significantly increased in patients with liver disease and suspected variceal bleeding who received TXA 1.

Key Points

• TXA should not be used to stop a GI bleed, especially in patients with cirrhosis and active variceal bleeding.
• Standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment.
• The correction of haemostatic abnormalities should be considered on a case-by-case basis.
• The use of blood products should be done cautiously to avoid increasing portal pressure and worsening outcomes.

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.