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

Tranexamic Acid (TXA) Is Not Recommended for GI Bleeding

Based on the most recent and highest quality evidence, tranexamic acid should not be used for the treatment of gastrointestinal bleeding as it does not reduce mortality from GI bleeding and may increase risk of venous thromboembolism. 1

Current Evidence on TXA for GI Bleeding

Guidelines Recommendations

The British Society of Gastroenterology (2019) clearly states that tranexamic acid use in acute lower gastrointestinal bleeding should be confined to clinical trials 2. Similarly, older guidelines on non-variceal upper GI hemorrhage (2002) noted that while meta-analyses showed tranexamic acid might reduce surgical intervention and mortality, further studies were necessary before it could be recommended as routine therapy 2.

Recent Clinical Trial Evidence

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

• Enrolled 12,009 patients with significant upper or lower GI bleeding
• Found that TXA did not reduce death due to bleeding within 5 days (4% in TXA group vs 4% in placebo group)
• Showed increased risk of venous thromboembolic events with TXA (0.8% vs 0.4% in placebo; RR 1.85) 1

This large, international, multicenter trial supersedes earlier, smaller studies and meta-analyses that had suggested potential benefits.

Management Algorithm for GI Bleeding

Instead of TXA, the following approach is recommended:

1. Initial Resuscitation:

   • Secure airway, breathing, circulation
   • IV fluid resuscitation
   • Blood product transfusion as needed

2. Medical Management:

   • For upper GI bleeding: High-dose proton pump inhibitors (80 mg omeprazole stat followed by 8 mg/hr infusion for 72 hours) 2
   • For patients on direct oral anticoagulants (DOACs): Interrupt therapy and consider reversal agents for life-threatening hemorrhage 2

3. Endoscopic Intervention:

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

4. Interventional Radiology or Surgery:

   • For uncontrolled hemorrhage that cannot be stopped by endoscopic intervention
   • For rebleeding after failed repeat endoscopic therapy 2

Special Considerations

Anticoagulated Patients

• For patients on DOACs with GI bleeding:
  • Interrupt DOAC therapy immediately
  • Consider specific reversal agents (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) for life-threatening hemorrhage
  • Consider restarting anticoagulation at maximum 7 days after bleeding stops 2

Organizational Aspects

• All hospitals should have a GI bleeding lead and agreed pathways for management
• Access to 7-day endoscopy services and 24/7 interventional radiology is essential 2

Common Pitfalls to Avoid

1. Using TXA based on older, smaller studies: Despite promising results in earlier meta-analyses, the definitive HALT-IT trial shows no mortality benefit and increased thrombotic risk 1

2. Delaying endoscopic intervention: Early endoscopy remains the cornerstone of management for both diagnosis and potential therapeutic intervention

3. Inappropriate reinitiation of anticoagulation: Consider waiting at least 7 days before restarting DOACs after a GI bleed 2

4. Failure to involve specialists: Complex cases should involve gastroenterologists and, when appropriate, hematologists for management of anticoagulation 2

While some case reports suggest TXA may be useful in specific scenarios such as Jehovah's Witness patients who refuse blood products 3, the highest quality evidence does not support its routine use for GI bleeding.