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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) should not be used routinely for the treatment of gastrointestinal bleeding as it does not reduce mortality and may increase the risk of venous thromboembolic events. 1

Evidence on TXA for Different Types of GI Bleeding

Variceal Bleeding

• TXA should not be used in patients with cirrhosis and active variceal bleeding (strong recommendation, Level of Evidence 2) 1
• Possible reasons for ineffectiveness in variceal bleeding include:
  • Limited role of haemostasis in variceal bleeding
  • Frequent occurrence of hypofibrinolytic state in critically ill patients with cirrhosis 1
• Risk of venous thromboembolic events is significantly higher in patients with liver disease receiving TXA 1

Non-Variceal Upper GI Bleeding

• High-dose IV TXA (≥4g/24h) shows no difference in mortality, rebleeding, or need for surgical intervention compared to placebo 1
• Increased rates of deep vein thrombosis (RR 2.10), pulmonary embolism (RR 1.78), and seizures (RR 1.73) have been observed with high-dose TXA 1
• The HALT-IT trial (n=12,009) found no beneficial effect of TXA on death due to bleeding within 5 days 2

Lower GI Bleeding

• Current guidelines suggest that use of TXA in acute lower GI bleeding should be confined to clinical trials 1
• The HALT-IT trial included both upper and lower GI bleeding patients and showed no mortality benefit 2

Special Considerations

Anorectal Varices

• For bleeding anorectal varices, guidelines suggest vasoactive drugs like terlipressin or octreotide rather than TXA 1
• Non-selective beta-blockers are recommended for prevention/prophylaxis of variceal bleeding 1

Hereditary Hemorrhagic Telangiectasia

• Oral TXA is recommended for mild GI bleeding in hereditary hemorrhagic telangiectasia patients due to low potential for harm, though evidence of effectiveness is limited 1
• For moderate to severe GI bleeding in these patients, systemic bevacizumab is preferred 1

Potential Exceptions

While the evidence does not support routine use, there may be specific scenarios where TXA could be considered:

1. Dialysis patients: A small non-randomized study showed TXA may be beneficial as adjunctive therapy in dialysis patients with major upper GI bleeding, reducing early rebleeding rates and need for blood transfusions 3

2. Patients who refuse blood products: Case reports suggest TXA may help achieve hemostasis in Jehovah's Witness patients with life-threatening GI bleeding who refuse blood products 4

Clinical Algorithm for TXA Use in GI Bleeding

1. Identify bleeding type and severity:

   • Variceal bleeding → Do NOT use TXA
   • Non-variceal bleeding → Consider standard treatments first (endoscopic therapy, PPI)

2. For most GI bleeding patients:

   • Standard care without TXA is recommended
   • Focus on endoscopic intervention, acid suppression, and correction of coagulopathy as appropriate

3. Special populations where TXA might be considered:

   • Patients with hereditary hemorrhagic telangiectasia with mild GI bleeding
   • Dialysis patients with major upper GI bleeding
   • Patients who refuse blood products

4. If TXA is used, monitor closely for:

   • Venous thromboembolism
   • Seizures
   • Arterial thrombotic events

Conclusion

Based on high-quality evidence from large randomized controlled trials, TXA does not improve mortality outcomes in GI bleeding and may increase thromboembolic complications. Standard endoscopic therapy, acid suppression, and correction of coagulopathy remain the cornerstones of GI bleeding management.