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

Tranexamic Acid Is Not Recommended for GI Bleeding Based on Current Evidence

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

Evidence Assessment

Guidelines on TXA for GI Bleeding

The most recent and highest quality evidence from guidelines indicates that tranexamic acid is not recommended for routine use in gastrointestinal bleeding:

• The 2019 British Society of Gastroenterology guidelines state that "use of tranexamic acid in acute LGIB is confined to clinical trials" 2
• The guidelines note that while TXA improves mortality in trauma when given intravenously, its benefit in GI bleeding is uncertain 2
• Earlier guidelines from 2002 also indicated that "further studies of tranexamic acid are necessary before it can be recommended as routine therapy" 2

Definitive Research Evidence

The HALT-IT trial (2020), which is the largest and most recent randomized controlled trial on this topic, provides the strongest evidence:

• This international, multicenter trial included 12,009 patients with significant upper or lower GI bleeding 1
• The trial found that TXA did not reduce death due to bleeding within 5 days compared to placebo (4% vs 4%, RR 0.99,95% CI 0.82-1.18) 1
• Importantly, venous thromboembolic events (DVT or PE) were significantly higher in the TXA group (0.8% vs 0.4%, RR 1.85,95% CI 1.15 to 2.98) 1

Management Algorithm for GI Bleeding

Instead of using TXA, the following approach is recommended for GI bleeding:

1. Initial Resuscitation

   • Secure airway, breathing, circulation
   • Establish IV access with large-bore catheters
   • Fluid resuscitation
   • Blood product transfusion as needed

2. Medication Management

   • For upper GI bleeding: High-dose proton pump inhibitors (e.g., omeprazole 80 mg stat followed by 8 mg/hour for 72 hours) 2
   • For patients on direct oral anticoagulants (DOACs): Interrupt therapy at presentation 2
   • For life-threatening bleeding on DOACs: Consider specific reversal agents like idarucizumab or andexanet 2

3. Endoscopic Intervention

   • Early endoscopy for diagnosis and potential therapeutic intervention
   • Repeat endoscopy if there is evidence of rebleeding 2

4. Interventional Radiology or Surgery

   • For uncontrolled hemorrhage that cannot be stopped by endoscopic intervention 2
   • For patients who rebleed after initial endoscopic therapy 2

Common Pitfalls and Caveats

• Misinterpreting older meta-analyses: Some earlier, smaller studies suggested benefit from TXA in GI bleeding 3, 4, but these have been superseded by the larger, more robust HALT-IT trial 1
• Case reports are not reliable evidence: While individual case reports may show successful use of TXA 5, these cannot be generalized to routine clinical practice
• Confusing trauma guidelines with GI bleeding guidelines: TXA is beneficial in trauma bleeding but this benefit does not extend to GI bleeding 2
• Restarting anticoagulation: For patients on DOACs who develop GI bleeding, consider restarting therapy at maximum 7 days after hemorrhage has stopped 2

Special Considerations

• For patients with ongoing bleeding despite standard management, endoscopic therapy remains the first-line approach, not TXA
• Hospitals should have established pathways for GI bleeding management with access to 24/7 endoscopy and interventional radiology services 2
• For patients at high risk of rebleeding who require anticoagulation, warfarin may be preferable to DOACs due to more effective and rapid reversal options 2