Can tranexamic acid (TXA) stop a gastrointestinal (GI) bleed?

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed, particularly 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 weigh the potential benefits against the risks. While TXA has been shown to improve mortality in trauma patients and has some evidence for its benefit in acute GI bleeding 1, its use in variceal bleeding is not recommended due to the lack of efficacy and increased risk of thromboembolic events 1. Some key points to consider when evaluating the use of TXA in GI bleeding include:

• The mechanism of action of TXA, which involves inhibiting plasminogen activation and preventing the breakdown of fibrin clots 1
• The potential benefits of TXA in reducing rebleeding rates and mortality in certain types of GI bleeding, such as upper GI bleeding 1
• The increased risk of venous thromboembolic events associated with TXA use, particularly in patients with cirrhosis and active variceal bleeding 1
• The importance of using TXA as part of a comprehensive management approach that may include endoscopic intervention, proton pump inhibitors, and other supportive measures In terms of specific patient populations, the use of TXA is not recommended in patients with cirrhosis and active variceal bleeding due to the lack of beneficial effect and increased risk of thromboembolic events 1. However, TXA may be considered in other types of GI bleeding, such as upper GI bleeding, where its benefits in reducing rebleeding rates and mortality have been more consistently demonstrated 1. The most recent and highest quality study on this topic, published in 2022, found that TXA had no beneficial effect in patients with acute upper gastrointestinal bleeding, including those with suspected variceal bleeding and liver disease comorbidity 1. This study also found an increased risk of venous thromboembolic events associated with TXA use, particularly in patients with comorbid liver disease or suspected variceal bleeding. Given the potential risks and lack of beneficial effect, TXA should not be used to stop a GI bleed, particularly in patients with cirrhosis and active variceal bleeding. Instead, other management strategies, such as endoscopic intervention, proton pump inhibitors, and supportive measures, should be prioritized.

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.