Tranexamic Acid for GI Bleeding
Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal 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 the routine use of TXA for GI bleeding:
- The British Society of Gastroenterology (2019) explicitly recommends that "use of tranexamic acid in acute LGIB is confined to clinical trials" 2
- The European Society of Intensive Care Medicine and American Gastroenterological Association recommend against routine use of high-dose IV TXA in GI bleeding 1
- The HALT-IT randomized controlled trial (2021), which is the largest and most definitive study on this topic, found that TXA did not reduce death from GI bleeding compared to placebo (3.7% vs 3.8%, risk ratio 0.99) 3
Risks Associated with TXA in GI Bleeding
TXA use in GI bleeding is associated with increased risk of adverse events:
- Significantly higher risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism) with TXA compared to placebo (0.8% vs 0.4%, risk ratio 1.85) 3
- Increased risk of seizures with TXA compared to placebo (0.6% vs 0.4%, risk ratio 1.73) 3
- High-dose TXA significantly increases risk of DVT (RR 2.10), pulmonary embolism (RR 1.78), and seizures (RR 1.73) 1
Preferred Management Approaches for GI Bleeding
Instead of TXA, the following evidence-based approaches should be prioritized:
For Upper GI Bleeding:
- High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour infusion for 72 hours) 2, 1
- Early endoscopic intervention for diagnosis and treatment 1
For Lower GI Bleeding:
- Fluid resuscitation to stabilize blood pressure 1
- Target hemoglobin of 70-90 g/L (higher threshold of 80-100 g/L for patients with cardiovascular disease) 1
- Early colonoscopy for diagnosis and potential endoscopic therapy 2
For Patients on Anticoagulants:
- Temporarily interrupt direct oral anticoagulant therapy at presentation 2
- Consider specific reversal agents for life-threatening hemorrhage (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) rather than adding TXA 2, 1
- Restart DOAC treatment at a maximum of 7 days after hemorrhage 2
Special Considerations
While some older, smaller studies suggested potential benefits of TXA in GI bleeding 4, these findings have been superseded by the HALT-IT trial, which provides the most reliable evidence to date. The economic analysis from this trial also found that TXA was not cost-effective and resulted in slightly poorer health outcomes than no TXA 3.
There may be rare exceptional circumstances where TXA might be considered, such as in patients who refuse blood products (e.g., Jehovah's Witnesses) 5, but this should be viewed as an extraordinary measure rather than standard care.