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. The use of TXA in GI bleeding is a topic of ongoing debate, with some studies suggesting a potential benefit in certain cases, such as upper GI bleeds 1. However, the most recent and highest quality study, published in 2022, found no beneficial effect of TXA in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. Some key points to consider when evaluating the use of TXA in GI bleeding include:
- The cause and location of the bleeding: TXA may be more beneficial for upper GI bleeds than lower GI bleeds 1.
- The presence of cirrhosis and portal hypertension: TXA should not be used in patients with cirrhosis and active variceal bleeding due to the lack of beneficial effect and potential increased risk of venous thromboembolic events 1.
- The risk of thromboembolic events: TXA should be used cautiously in patients with a history of thromboembolism, as it could potentially increase clotting risk 1. In general, TXA should be used as part of a comprehensive approach to managing GI bleeding, rather than as a standalone treatment. The decision to use TXA should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of treatment. The standard therapy for variceal bleeding includes prompt initiation of vasoactive therapy, antibiotics, and endoscopic treatment, and TXA is not considered a first-line therapy for most GI bleeds 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.