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

Tranexamic Acid (TXA) for GI Bleeding

High-dose intravenous tranexamic acid is not recommended for patients with gastrointestinal bleeding due to lack of mortality benefit and increased risk of thrombotic events. 1

Evidence Summary

The European Society of Intensive Care Medicine (2021) provides high-certainty evidence against using high-dose IV TXA (≥4g/24h) in GI bleeding, based on multiple studies including the large HALT-IT trial 1:

• No mortality benefit (RR 0.98,95% CI 0.88-1.09)
• No reduction in rebleeding (RR 0.92,95% CI 0.82-1.04)
• No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09)
• Increased risk of deep vein thrombosis (RR 2.10,95% CI 1.08-3.72)
• Increased risk of pulmonary embolism (RR 1.78,95% CI 1.06-3.0)
• Increased risk of seizures (RR 1.73,95% CI 1.03-2.93)

Potential Exceptions and Uncertainties

There is moderate-certainty evidence that low-dose IV or enteral TXA may:

• Reduce rebleeding (RR 0.5,95% CI 0.38-0.88)
• Reduce need for surgical intervention (RR 0.58,95% CI 0.38-0.88)
• Possibly reduce mortality (RR 0.62,95% CI 0.36-1.09)

However, the European guidelines make no recommendation regarding low-dose IV or enteral TXA due to imprecision in these results and limited data on potential harms 1.

Special Populations

In certain specific scenarios, TXA may be considered:

1. Jehovah's Witness patients: Case reports suggest TXA may be beneficial when blood transfusions are refused 2

2. Dialysis patients: A small non-randomized trial showed benefits of TXA in dialysis patients with upper GI bleeding, including decreased early rebleeding rates and fewer blood transfusions 3

3. Non-GI bleeding contexts: TXA is recommended for trauma patients within 3 hours of injury (Grade 1A/1B evidence) 1

Algorithm for TXA Use in GI Bleeding

1. For standard GI bleeding cases:

   • Do not administer high-dose IV TXA
   • Focus on standard management: endoscopic therapy, fluid resuscitation, blood product replacement as needed

2. For patients with contraindications to standard therapy:

   • Consider low-dose IV or enteral TXA as adjunctive therapy
   • Monitor closely for thrombotic complications

3. For patients with severe bleeding who cannot receive blood products:

   • Consider TXA (1g IV followed by 1g over 8h) as adjunctive therapy
   • Weigh risks of thrombotic complications against potential benefits

Important Caveats

• The British Society of Gastroenterology (2019) suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials 1
• Antifibrinolytics like TXA may be considered in special situations with associated coagulopathy or thrombopathy 1
• Recent meta-analyses suggest TXA may reduce rebleeding rates and surgical interventions in upper GI bleeding, but effects on mortality remain uncertain 4, 5

In conclusion, while TXA is effective in trauma-related bleeding, the current high-quality evidence does not support its routine use for GI bleeding outside of specific clinical scenarios.