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

Tranexamic Acid for Gastrointestinal Bleeding

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

Evidence Assessment

The most recent and high-quality evidence from clinical guidelines strongly advises against the routine use of TXA for GI bleeding:

• The 2025 Management of Gastrointestinal Bleeding guidelines explicitly recommend against routine use of high-dose IV tranexamic acid in GI bleeding 1
• This recommendation is supported by the HALT-IT trial, a large international randomized controlled trial (n=12,009) that found TXA did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) 2
• The British Society of Gastroenterology (2019) suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 3

Risks of TXA in GI Bleeding

TXA use in GI bleeding is associated with significant risks:

• Increased thromboembolic events:
  • Higher rates of venous thromboembolism (RR 1.85; 95% CI 1.15 to 2.98) 2
  • Specifically increased risk of deep vein thrombosis (RR 2.10), pulmonary embolism (RR 1.78), and seizures (RR 1.73) 1

Alternative Management Strategies for GI Bleeding

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

1. Initial resuscitation and stabilization:

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

2. Pharmacological management:

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

3. Endoscopic intervention:

   • Early endoscopy for diagnosis and therapeutic intervention
   • Repeat endoscopy for ongoing or recurrent bleeding 1

4. Interventional radiology or surgery:

   • For bleeding that cannot be controlled endoscopically 1

Special Considerations

For patients on anticoagulants with GI bleeding:

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

Clinical Pitfalls to Avoid

• Do not use TXA based on its success in trauma or postpartum hemorrhage: Despite TXA's proven benefits in trauma and postpartum hemorrhage, this does not translate to GI bleeding 3, 2

• Avoid being misled by older, smaller studies: While some older meta-analyses of small trials suggested potential benefits 4, 5, the definitive HALT-IT trial with over 12,000 patients showed no mortality benefit but increased thrombotic risk 2

• Case reports are not sufficient evidence: While individual case reports may describe successful use of TXA in specific scenarios 6, these do not override the high-quality evidence from large randomized controlled trials

The evidence clearly demonstrates that tranexamic acid should not be used for gastrointestinal bleeding outside the context of a clinical trial.