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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) should not be used routinely for the treatment of gastrointestinal bleeding as it does not reduce mortality or rebleeding rates but increases the risk of thromboembolic events. 1, 2

Current Evidence on TXA for GI Bleeding

High-Quality Evidence Against Routine Use

The European Society of Intensive Care Medicine explicitly recommends against using high-dose intravenous TXA in critically ill patients with gastrointestinal bleeding based on high-certainty evidence 1. This recommendation is supported by the large HALT-IT trial, which found:

• No difference in mortality (RR 0.98,95% CI 0.88-1.09) 1, 3
• No reduction in rebleeding rates (RR 0.92,95% CI 0.82-1.04) 1
• No decrease in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1

Increased Risk of Adverse Events

High-dose TXA significantly increases the risk of:

• Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1, 2
• Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1, 2
• Seizures (RR 1.73,95% CI 1.03-2.93) 1, 2

Standard of Care for GI Bleeding Management

Instead of TXA, the standard management for GI bleeding should include:

Initial Assessment and Stabilization

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

Pharmacological Management

• High-dose proton pump inhibitor therapy for upper GI bleeding 1
• Terlipressin for patients with suspected cirrhosis/variceal bleeding 1

Endoscopic and Radiological Management

• Early endoscopy for diagnosis and therapeutic intervention 1
• Interventional radiology for bleeding that cannot be controlled endoscopically 1

Special Circumstances for TXA Use

While routine use is not recommended, there may be specific scenarios where TXA could be considered:

1. Patients refusing blood products: In Jehovah's Witness patients or others who refuse blood transfusions, TXA might be considered as a last-resort option 4

2. Low-dose or enteral TXA: The European Society of Intensive Care Medicine makes no recommendation regarding low-dose IV or enteral TXA due to insufficient evidence 1

Clinical Pitfalls to Avoid

1. Overestimating TXA benefits: Despite some older, smaller studies suggesting benefit 5, 6, the most recent and highest quality evidence from the HALT-IT trial shows no mortality benefit 3

2. Ignoring thromboembolic risk: The increased risk of venous thromboembolism with TXA in GI bleeding patients is significant and must be considered 1, 2, 3

3. Delaying definitive treatment: Using TXA should not delay endoscopic evaluation and intervention, which remains the standard of care for GI bleeding 1

In conclusion, while TXA has proven benefits in trauma and postpartum hemorrhage, the current high-quality evidence does not support its routine use in GI bleeding. Management should focus on established interventions including fluid resuscitation, proton pump inhibitors, and early endoscopic evaluation and treatment.