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

Tranexamic Acid for Lower GI Bleeding

Tranexamic acid (TXA) is not recommended for stopping lower gastrointestinal bleeding based on current evidence. 1

Evidence on TXA for Lower GI Bleeding

The British Society of Gastroenterology (2019) explicitly recommends that the use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 1. This recommendation is based on the following considerations:

• While TXA has shown mortality benefits in trauma settings when given intravenously in the acute setting, evidence for GI bleeding is less clear
• Historical trials in upper GI bleeding showed a potential 40% risk reduction in mortality, but this benefit disappeared when analysis was limited to trials with low risk of bias
• Older studies were conducted before the routine use of modern therapeutic approaches like high-dose acid suppression and endoscopic therapy

Recent research further supports this position:

• A 2024 randomized controlled trial found that intravenous TXA had no significant effect on blood transfusion requirements in patients with lower GI bleeding 2
• A 2018 randomized placebo-controlled trial concluded that TXA does not appear to decrease blood loss or improve clinical outcomes in patients with lower GI bleeding 3
• A 2022 meta-analysis showed that extended-use high-dose IV TXA did not reduce mortality or bleeding but increased risk of deep venous thrombosis, pulmonary embolism, and seizures 4

Recommended Management Approach for Lower GI Bleeding

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

1. Initial assessment and resuscitation:

   • Assess hemodynamic status and initiate fluid resuscitation as needed
   • Consider RBC transfusion with a threshold of 70 g/L (aiming for 70-100 g/L) 1
   • Higher transfusion threshold may be appropriate in patients with cardiovascular disease

2. Diagnostic workup:

   • Colonoscopy should be the initial diagnostic procedure in most patients
   • Perform within 24 hours of presentation after adequate colon preparation 1
   • For patients with severe ongoing bleeding, consider CT angiography

3. Therapeutic options:

   • Endoscopic therapy for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot)

     • Options include injection therapy (epinephrine), endoscopic clipping, thermal therapies, and endoscopic band ligation 1
     • For diverticular bleeding, endoscopic band ligation may have lower rebleeding rates (6%) compared to clipping (33%) 1

   • Interventional radiology if endoscopy fails or is not feasible

     • Embolization can be performed using coils, liquid agents, or particles
     • Technical success rates are high (93-100%), but bowel ischemia is a potential complication 1

4. Management of anticoagulants:

   • For patients on direct oral anticoagulants (DOACs), temporarily interrupt therapy
   • In life-threatening hemorrhage, consider reversal agents:
     • Idarucizumab for dabigatran
     • Andexanet alfa for factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) 1
   • Restarting DOACs at 7 days after hemorrhage is reasonable in most cases 1

Pitfalls and Caveats

• Do not use TXA as a routine treatment for lower GI bleeding outside of clinical trials 1, 5
• Avoid NSAIDs in patients with a history of lower GI bleeding, particularly if secondary to diverticulosis or angioectasia
• For patients with established high-risk cardiovascular disease, do not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding
• Consider the risk of thrombotic events (approximately 10% within 30 days) when using andexanet alfa for DOAC reversal 1
• Ensure prompt resumption of anticoagulation after major bleeding once it is safe to do so

The management of lower GI bleeding requires a coordinated approach with access to endoscopy, interventional radiology, and surgical services, with all hospitals ideally having a GI bleeding lead and agreed pathways for management 1.