From the Guidelines
Tranexamic acid (TXA) should not be used to stop a GI bleed, especially in patients with cirrhosis and variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. The use of TXA in GI bleeding is still a topic of debate, with some studies suggesting a potential benefit in upper GI bleeds, but the most recent and highest quality evidence does not support its routine use 1. In fact, a large randomized placebo-controlled trial found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, and an increased risk of venous thromboembolic events, particularly in patients with comorbid liver disease or suspected variceal bleeding 1.
The primary management of GI bleeds should focus on addressing the underlying cause, such as using proton pump inhibitors for peptic ulcers, endoscopic interventions for visible vessels, or vasoactive drugs for variceal bleeding. TXA may be considered as an adjunctive therapy in specific cases, but its use should be cautious and individualized, taking into account the patient's risk of thrombotic complications. The British Society of Gastroenterology guidelines suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial 1.
Some key points to consider when managing GI bleeds include:
- Identifying and addressing the underlying cause of the bleed
- Using endoscopic interventions and vasoactive drugs as first-line treatments
- Considering the use of TXA as an adjunctive therapy in specific cases, but with caution and individualized assessment of thrombotic risk
- Being aware of the potential risks and benefits of TXA, including the increased risk of thromboembolic events in patients with comorbid liver disease or suspected variceal bleeding.
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.