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

Tranexamic Acid for Gastrointestinal Bleeding

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

Evidence Against Routine TXA Use 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 recommend against the routine use of high-dose IV tranexamic acid in gastrointestinal bleeding 1

• TXA significantly increases the risk of thromboembolic complications:

  • 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

• The HALT-IT trial, a large international randomized controlled trial with 12,009 patients, found that TXA did not reduce death from gastrointestinal bleeding compared to placebo (4% vs 4%, RR 0.99,95% CI 0.82-1.18) 2

• This trial also demonstrated higher rates of venous thromboembolic events in the TXA group (0.8% vs 0.4%, RR 1.85,95% CI 1.15 to 2.98) 2

Recommended Management for GI Bleeding

Instead of TXA, current guidelines recommend:

1. Initial resuscitation and stabilization:

   • Target hemoglobin of 70-90 g/L for most patients (higher threshold of 80-100 g/L for those with cardiovascular disease) 3, 1

2. Pharmacological management:

   • High-dose proton pump inhibitor therapy for upper GI bleeding 1
   • Terlipressin for suspected cirrhosis or variceal bleeding 3, 1

3. Endoscopic and interventional approaches:

   • Early endoscopy for diagnosis and therapeutic intervention 1
   • Endoscopic treatments based on bleeding source (band ligation for varices, thermal/injection therapy for ulcers) 1
   • Interventional radiology or surgery for uncontrolled hemorrhage after failed endoscopic intervention 1

Special Considerations

• For patients with cirrhosis and active variceal bleeding: TXA is specifically contraindicated (strong recommendation) 1
• For patients on anticoagulants: Consider specific reversal agents for life-threatening hemorrhage (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) rather than adding TXA 1, 3

Diagnostic Approach for GI Bleeding

For patients with suspected GI bleeding:

• If hemodynamically unstable (shock index >1), CT angiography is recommended as the fastest means to localize bleeding 3
• For stable patients, endoscopy remains the primary diagnostic tool 3, 1
• If no source is identified by CTA and upper GI bleeding is suspected, immediate upper endoscopy should be performed 3

While some older, smaller studies suggested potential benefits of TXA in GI bleeding 4, 5, the most recent and largest trial (HALT-IT) definitively showed no mortality benefit with increased thromboembolic risk, leading to the current recommendation against its routine use 2, 1.