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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal (GI) bleeding as it does not reduce mortality or rebleeding rates but increases the risk of thromboembolic events. 1

Evidence Against TXA in GI Bleeding

The most recent and highest quality evidence strongly advises against using TXA for GI bleeding:

• The European Society of Intensive Care Medicine and the American Gastroenterological Association explicitly recommend against routine use of high-dose IV tranexamic acid in GI bleeding 1
• The HALT-IT trial, a large international randomized controlled trial published in 2020, found that TXA:
  • Did not reduce death from GI bleeding (RR 0.99,95% CI 0.82-1.18) 2
  • Increased venous thromboembolic events (deep vein thrombosis or pulmonary embolism) with RR 1.85 (95% CI 1.15 to 2.98) 2

Risks Associated with TXA in GI Bleeding

TXA significantly increases thromboembolic risks in GI bleeding patients:

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

Current Guidelines for GI Bleeding Management

Instead of TXA, the British Society of Gastroenterology recommends:

1. First-line treatments:

   • High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) for upper GI bleeding 1
   • Early endoscopy for diagnosis and therapeutic intervention 3, 1
   • Terlipressin for suspected cirrhosis or variceal bleeding 1

2. For patients on anticoagulants:

   • Temporarily interrupt direct oral anticoagulants (DOACs)
   • Use specific reversal agents when necessary (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) 1
   • Consider warfarin over DOACs in patients at high risk of rebleeding due to more effective reversal options 3

3. For refractory bleeding:

   • Repeat endoscopy for confirmation and attempt at endoscopic therapy 1
   • Consider interventional radiology for bleeding that cannot be controlled endoscopically 3, 1
   • Surgical intervention for uncontrolled hemorrhage after failed endoscopic and radiological approaches 1

Important Clinical Considerations

• While some older, smaller studies suggested potential benefits of TXA in GI bleeding 4, 5, these findings have been superseded by the much larger and more robust HALT-IT trial 2
• The British Society of Gastroenterology specifically states that "at this time we suggest that use of tranexamic acid in acute LGIB is confined to clinical trials" 3
• There may be rare exceptional circumstances (such as Jehovah's Witness patients refusing blood products) where TXA might be considered as a last resort 6, but this is not supported by current guidelines for routine care

Common Pitfalls to Avoid

• Don't use TXA routinely for GI bleeding based on its success in trauma or postpartum hemorrhage settings
• Don't delay definitive interventions (endoscopy, interventional radiology, or surgery) while trying pharmacological approaches that lack evidence
• Don't overlook the significant thromboembolic risks associated with TXA in GI bleeding patients
• Don't confuse the positive results of TXA in trauma with its ineffectiveness in GI bleeding