From the Guidelines
Tranexamic acid (TXA) should not be used to stop a GI bleed, particularly in cases of variceal bleeding, due to the lack of beneficial effect and increased risk of thromboembolic events. The most recent and highest quality study, published in 2022 in the Journal of Hepatology 1, found that TXA did not reduce mortality or re-bleeding rates in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding. In fact, the study reported a nearly 2-fold increase in the incidence of venous thromboembolic events in the TXA group compared to the placebo group.
When considering the use of TXA in GI bleeding, it's essential to distinguish between different types of bleeding, such as mucosal bleeding versus variceal bleeding. While TXA may be effective in reducing mortality in upper GI bleeding, its effectiveness varies depending on the cause and location of the bleed. However, the latest evidence suggests that TXA is not beneficial in variceal bleeding, and its use may even be harmful due to the increased risk of thromboembolic events.
Key points to consider when evaluating the use of TXA in GI bleeding include:
- The cause and location of the bleed
- The presence of variceal bleeding or portal hypertension
- The patient's history of thrombosis or severe renal impairment
- The potential for increased risk of thromboembolic events
In general, TXA should be used cautiously and only in specific cases where the benefits outweigh the risks. The 2019 guidelines from the British Society of Gastroenterology 1 suggest that the use of TXA in acute lower GI bleeding should be confined to clinical trials, pending the results of further studies. However, the more recent study published in 2022 1 provides stronger evidence against the use of TXA in variceal bleeding, and its findings should be prioritized in clinical decision-making.
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.