From the Guidelines
Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, as the most recent and highest quality evidence does not support its effectiveness in this context. The standard approach for managing GI bleeds includes resuscitation, hemodynamic stabilization, correction of coagulopathy, and rapid referral for endoscopic or surgical management. For acute upper GI bleeds, proton pump inhibitors (such as pantoprazole 80mg IV bolus followed by 8mg/hr infusion), endoscopic intervention, and blood product support as needed are recommended. For lower GI bleeds, colonoscopy and interventional radiology are preferred. The HALT-IT trial, a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding, found that TXA did not reduce mortality in GI bleeding and was associated with an increased risk of venous thromboembolism 1. In specific scenarios like severe bleeding with delayed access to definitive care, TXA might be considered as a temporizing measure, but it should not replace standard treatments. Key considerations in managing GI bleeds include:
- Resuscitation and hemodynamic stabilization
- Correction of coagulopathy
- Rapid referral for endoscopic or surgical management
- Use of proton pump inhibitors and endoscopic intervention for upper GI bleeds
- Use of colonoscopy and interventional radiology for lower GI bleeds The evidence from the HALT-IT trial 1 and other studies 1 suggests that TXA is not effective in reducing mortality from GI bleeding and may increase the risk of thromboembolic events. Therefore, TXA should not be used as a first-line treatment for GI bleeds, and standard treatments should be prioritized instead.
From the Research
Effectiveness of Tranexamic Acid (TXA) in Stopping GI Bleed
- TXA has been shown to be effective in reducing the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper gastrointestinal bleeding 2.
- A pilot study found that TXA was beneficial in treating major upper gastrointestinal bleeding in dialysis patients, reducing the rate of early re-bleeding, repeated endoscopic procedures, and blood transfusions needed 3.
- A systematic review suggested that TXA may reduce all-cause mortality in patients with upper gastrointestinal bleeding, but the evidence was limited by the internal and external validity of the included trials 4.
- Another systematic review and meta-analysis found that extended-use high-dose IV TXA did not improve mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 5.
- A large randomized controlled trial found that TXA did not reduce death from gastrointestinal bleeding and was not cost-effective in adults with acute gastrointestinal bleeding 6.
Key Findings
- TXA may be effective in reducing bleeding and mortality in patients with upper gastrointestinal bleeding, but the evidence is not consistent across all studies.
- The effectiveness of TXA in lower gastrointestinal bleeding is less clear and requires further clarification.
- High-dose IV TXA may increase the risk of thromboembolic events, such as deep-vein thrombosis and pulmonary embolism.
- Low-dose IV/enteral TXA may be a safer and more effective option for reducing hemorrhage in patients with gastrointestinal bleeding.