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 1. When considering the use of TXA in GI bleeding, it's essential to differentiate between upper and lower GI bleeding, as well as the underlying cause of the bleed.
- For upper GI bleeding, TXA may be considered in specific situations, such as when endoscopy is delayed or unavailable, but its use should be cautious and weighed against the potential risks, particularly in patients with thromboembolic risk factors or renal impairment.
- The dosage and treatment duration of TXA can vary, but typical regimens include 1 gram intravenously every 6-8 hours or 1-1.5 grams orally three to four times daily, with treatment lasting 3-7 days depending on bleeding control. However, the most recent and highest-quality evidence suggests that TXA has no beneficial effect in variceal bleeding and may even increase the risk of thromboembolic events 1. In patients with cirrhosis and active bleeding related to portal hypertension, correction of coagulopathy by transfusion of blood products is not recommended, as it may paradoxically increase bleeding rather than contribute to control of bleeding 1. Ultimately, the decision to use TXA in GI bleeding should be made on a case-by-case basis, taking into account the individual patient's risk factors, underlying cause of bleeding, and potential benefits and risks of treatment, with a strong recommendation against its use in patients with cirrhosis and active variceal bleeding 1.
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.