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

Tranexamic Acid Is Not Recommended for GI Bleeding

Tranexamic acid (TXA) is not recommended for the treatment of gastrointestinal bleeding as it does not reduce mortality and may increase the risk of venous thromboembolism. The Association of Anaesthetists explicitly states that tranexamic acid is not recommended for gastrointestinal bleeding in their 2025 guidelines 1.

Evidence Against TXA in GI Bleeding

Guidelines

The Association of Anaesthetists' 2025 guidelines specifically list gastrointestinal bleeding as "not recommended" in their table of suggested dosing schedules for tranexamic acid 1. This represents the most current guideline position on TXA use in GI bleeding.

The American College of Cardiology/American Heart Association 2024 guidelines note that while tranexamic acid safely decreases intraoperative bleeding in surgical settings, they do not endorse its use for GI bleeding 1.

Research Evidence

The HALT-IT trial, one of the largest randomized controlled trials on this topic, demonstrated that:

• TXA did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) 2
• TXA increased the risk of venous thromboembolic events (0.8% vs. 0.4%; RR 1.85,95% CI 1.15-2.98) 2
• TXA increased the risk of seizures (0.6% vs. 0.4%; RR 1.73,95% CI 1.03-2.93) 2

A 2022 meta-analysis found that extended-use high-dose IV tranexamic acid:

• Did not reduce mortality (RR 0.98,95% CI 0.88-1.09)
• Did not reduce bleeding (RR 0.92,95% CI 0.82-1.04)
• Increased risk of deep venous thrombosis (RR 2.01,95% CI 1.08-3.72)
• Increased risk of pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 3

Conflicting Evidence

While the most recent comprehensive meta-analysis from 2025 suggests TXA may reduce rebleeding rates (RR: 0.81,95% CI: 0.87-0.97) and mortality in upper GI bleeding (RR: 0.72,95% CI: 0.59-0.87), it also found increased mortality in lower GI bleeding (RR: 1.67,95% CI: 1.44-1.93) 4. This inconsistency across different types of GI bleeding raises concerns about its universal application.

Management Approach for GI Bleeding

Instead of TXA, focus on:

1. Initial resuscitation:

   • Fluid resuscitation if hemodynamically unstable
   • Restrictive transfusion strategy (target Hb 70-100 g/L) 1

2. Risk stratification:

   • Assess for signs of ongoing bleeding
   • Evaluate comorbidities, especially cardiovascular disease

3. Pharmacological therapies:

   • Consider terlipressin for suspected cirrhosis/variceal bleeding 1

4. Definitive management:

   • Timely access to endoscopy
   • Interventional radiology when appropriate
   • Surgical intervention if necessary

Important Considerations

• For patients with cardiovascular disease, consider a higher transfusion threshold 1
• Airway protection is critical in patients with ongoing hematemesis and altered mental status 1
• Nearly one-third of patients with lower GI bleeding receive RBC transfusions, but up to 80% may be inappropriate 1

Conclusion

Based on the most recent and highest quality evidence, TXA should not be used for the treatment of gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic complications. Focus instead on prompt resuscitation, appropriate blood transfusion strategies, and definitive management with endoscopy, interventional radiology, or surgery.