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

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a GI bleed, especially in patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect and may even increase the risk of venous thromboembolic events. TXA works by inhibiting fibrinolysis, which helps stabilize blood clots that form at bleeding sites. However, its use in GI bleeding is still a topic of debate, and recent studies have shed more light on its efficacy and safety. According to a 2022 study published in the Journal of Hepatology 1, TXA should not be used in patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect in reducing mortality or re-bleeding rates. In fact, the study found that TXA may even increase the risk of venous thromboembolic events, particularly in patients with comorbid liver disease or suspected variceal bleeding.

The use of TXA in GI bleeding is complex and depends on various factors, including the type and location of the bleed, as well as the presence of underlying conditions such as cirrhosis. While some studies have suggested that TXA may be beneficial in reducing mortality in certain bleeding scenarios, its efficacy varies widely depending on the specific context. For example, a 2019 study published in Gut 1 found that TXA may be beneficial in reducing mortality in acute lower GI bleeding, but the evidence was not strong enough to support its routine use.

In terms of dosing, TXA is typically administered as 1 gram intravenously every 6-8 hours for 24-48 hours, or until bleeding is controlled. However, the optimal dosing regimen for TXA in GI bleeding is still unclear, and more studies are needed to determine its safety and efficacy in different patient populations. 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 underlying conditions, the type and severity of the bleed, and the potential risks and benefits of treatment.

Some key points to consider when using TXA in GI bleeding include:

• TXA should not be used in patients with cirrhosis and active variceal bleeding, as it has been shown to have no beneficial effect and may even increase the risk of venous thromboembolic events 1.
• The use of TXA in GI bleeding is complex and depends on various factors, including the type and location of the bleed, as well as the presence of underlying conditions such as cirrhosis.
• The optimal dosing regimen for TXA in GI bleeding is still unclear, and more studies are needed to determine its safety and efficacy in different patient populations.
• TXA should be considered as an adjunct to standard treatments like endoscopic intervention, proton pump inhibitors, and blood product replacement when needed.

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.