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

Tranexamic Acid Is Not Recommended for GI Bleeding

Based on the most recent high-quality evidence, tranexamic acid (TXA) should not be used for the treatment of gastrointestinal bleeding as it does not reduce mortality from GI bleeding and may increase the risk of venous thromboembolic events. 1

Current Evidence on TXA for GI Bleeding

Guidelines Recommendations

The British Society of Gastroenterology (2019) clearly states that the use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials, pending the results of the HALT-IT trial. 2 This recommendation was based on the understanding that while there was some historical evidence suggesting potential benefit, the quality of evidence was low.

Similarly, older guidelines on non-variceal upper GI hemorrhage (2002) noted that while a meta-analysis had shown tranexamic acid might reduce surgical intervention and mortality in ulcer bleeding patients, further studies were necessary before it could be recommended as routine therapy. 2

Definitive Evidence from HALT-IT Trial

The HALT-IT trial (2020), which is the most recent and highest quality evidence available, provides definitive guidance on this question:

• Large international randomized controlled trial (12,009 patients)
• 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/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. Medical Management

   • For upper GI bleeding: High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) 2
   • Interrupt direct oral anticoagulants if patient is on them 2
   • Consider reversal agents for DOACs in life-threatening hemorrhage (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) 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 2

Important Caveats and Pitfalls

• Older meta-analyses showed benefit: Some older, smaller studies and meta-analyses suggested TXA might be beneficial for GI bleeding 3, 4, but these have been superseded by the definitive HALT-IT trial.

• Case reports may be misleading: While individual case reports may show successful use of TXA in specific scenarios 5, these do not provide sufficient evidence for general recommendations.

• Thromboembolic risk: The increased risk of venous thromboembolism with TXA in GI bleeding patients (nearly double the risk) must be taken seriously. 1

• Avoid confusing with trauma protocols: While TXA is beneficial in trauma and postpartum hemorrhage, this benefit does not extend to GI bleeding. Clinicians familiar with trauma protocols should avoid automatically applying the same approach to GI bleeding.

• DOAC management: For patients on direct oral anticoagulants with GI bleeding, the focus should be on temporarily interrupting the DOAC and using specific reversal agents if necessary, rather than adding TXA. 2

The evidence is clear that despite theoretical benefits and historical suggestions of efficacy, TXA does not improve mortality in GI bleeding and may cause harm through increased thromboembolic events.