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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) should not be used routinely for the management of gastrointestinal bleeding as it does not reduce rebleeding rates or mortality but increases the risk of thromboembolic events.

Evidence Assessment

The most recent and highest quality evidence comes from the 2021 European Society of Intensive Care Medicine guidelines 1 and the 2020 HALT-IT trial 2, which provide high-certainty evidence against the routine use of high-dose IV TXA in GI bleeding.

The HALT-IT trial, a large international randomized controlled trial including over 12,000 patients, found that:

• TXA did not reduce death due to bleeding (RR 0.99,95% CI 0.82-1.18)
• TXA increased the risk of venous thromboembolic events (RR 1.85,95% CI 1.15-2.98)
• No benefit was seen for rebleeding or need for surgical intervention

Management Algorithm for GI Bleeding

Initial Management

1. Resuscitation and stabilization

   • Fluid resuscitation to stabilize blood pressure 1
   • Target hemoglobin of 70-90 g/L for most patients 1
   • Higher threshold (80-100 g/L) for patients with cardiovascular disease 1

2. Risk stratification

   • Clinical assessment including vital signs, comorbidities, and bleeding severity 1
   • Laboratory evaluation including hemoglobin level and coagulation parameters

Pharmacological Management

1. Proton pump inhibitors

   • High-dose IV PPI (80 mg bolus followed by 8 mg/hour infusion for 72 hours) for upper GI bleeding 3

2. Vasoactive agents for suspected variceal bleeding

   • Terlipressin for those with suspected cirrhosis/variceal bleeding 1

3. Tranexamic acid

   • Do not use high-dose IV TXA (4 g/24h or greater) for GI bleeding 1, 2
   • No recommendation regarding low-dose IV or enteral TXA due to insufficient evidence 1

Endoscopic Management

1. Early endoscopy for diagnosis and therapeutic intervention 3
2. Repeat endoscopy for ongoing or recurrent bleeding 3

Rescue Therapies

1. Interventional radiology for bleeding that cannot be controlled endoscopically 3
2. Surgical intervention for uncontrolled hemorrhage after failed endoscopic and radiological approaches 3

Special Considerations

Patients Who Cannot Receive Blood Products

In rare cases where patients refuse blood products (e.g., Jehovah's Witnesses), TXA might be considered as a last resort therapy 4, but this should not be standard practice.

Patients on Anticoagulants

For patients on direct oral anticoagulants with GI bleeding:

• Temporarily interrupt the anticoagulant
• Consider specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) if necessary 3
• Do not add TXA routinely

Pitfalls and Caveats

1. Older studies vs. newer evidence: Some older meta-analyses suggested benefits of TXA in GI bleeding 5, 6, but these have been superseded by the high-quality HALT-IT trial 2.

2. Thromboembolic risk: TXA significantly increases the risk of venous thromboembolism in GI bleeding patients (DVT risk: RR 2.10,95% CI 1.08-3.72; PE risk: RR 1.78,95% CI 1.06-3.0) 1.

3. Seizure risk: TXA increases seizure risk (RR 1.73,95% CI 1.03-2.93) 1.

4. Confusion with trauma protocols: While TXA is beneficial in trauma and postpartum hemorrhage 1, this benefit does not extend to GI bleeding. Clinicians familiar with trauma protocols should avoid automatically applying the same approach to GI bleeding.

In conclusion, current high-quality evidence does not support the routine use of TXA for GI bleeding. Management should focus on appropriate resuscitation, early endoscopy, and established pharmacological therapies like proton pump inhibitors.