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

Tranexamic Acid for GI Bleeding

Tranexamic acid (TXA) should not be used as routine therapy for gastrointestinal bleeding as it does not reduce rebleeding rates and has not demonstrated mortality benefit in the largest and most recent clinical trial. 1, 2

Current Guidelines and Evidence

The British Society of Gastroenterology and American Gastroenterological Association do not recommend TXA as routine therapy for GI bleeding 1. This recommendation is strongly supported by the HALT-IT trial, a large international randomized controlled trial with 12,009 patients, which found that TXA did not reduce death due to gastrointestinal bleeding compared to placebo (4% vs 4%, RR 0.99,95% CI 0.82-1.18) 2.

Additionally, the HALT-IT trial raised safety concerns by demonstrating that venous thromboembolic events (DVT or PE) were significantly higher in the TXA group compared to placebo (0.8% vs 0.4%, RR 1.85,95% CI 1.15 to 2.98) 2.

Recommended Management for GI Bleeding

Instead of TXA, the following evidence-based approaches should be prioritized:

1. Pharmacological management:

   • High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) 1
   • Consider somatostatin in select cases 1

2. Endoscopic management:

   • Early endoscopy for diagnosis and therapeutic intervention 1
   • Repeat endoscopy for confirmation and attempt at endoscopic therapy for ongoing or recurrent bleeding 1

3. For refractory bleeding:

   • Consider interventional radiology for bleeding that cannot be controlled endoscopically 1
   • Surgical intervention for uncontrolled hemorrhage after failed endoscopic and radiological approaches 1

Conflicting Evidence and Limitations

It's worth noting that some earlier, smaller meta-analyses suggested potential benefits of TXA in GI bleeding. A 2021 meta-analysis of 13 randomized controlled trials (n=2,271) suggested that TXA reduced continued bleeding (RR=0.60), urgent endoscopic intervention (RR=0.35), and mortality (RR=0.60) 3. However, these findings are overshadowed by the much larger and more recent HALT-IT trial 2.

Special Considerations

There may be rare circumstances where TXA could be considered:

• In patients who refuse blood products (e.g., Jehovah's Witnesses) as described in a case report where TXA was used successfully in an 80-year-old Jehovah's Witness patient with life-threatening GI bleeding 4
• When other standard therapies have failed or are contraindicated

Common Pitfalls to Avoid

• Do not delay endoscopic evaluation and intervention while waiting for TXA to take effect
• Do not use TXA as a substitute for definitive management (endoscopic, radiological, or surgical)
• Be aware of the increased risk of thromboembolic events with TXA use
• For patients on direct oral anticoagulants with GI bleeding, focus on temporarily interrupting the DOAC and using specific reversal agents rather than adding TXA 1

In conclusion, current guidelines and high-quality evidence do not support the routine use of TXA for GI bleeding, and standard approaches focusing on endoscopic intervention and appropriate pharmacological management should be prioritized.