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

Tranexamic Acid for GI Bleeding: Current Evidence and Recommendations

Tranexamic acid (TXA) should not be used for the treatment of gastrointestinal bleeding as it does not reduce death from GI bleeding and may increase the risk of venous thromboembolic events. 1

Evidence Assessment

Primary Evidence on TXA for GI Bleeding

The most recent and highest quality evidence comes from the HALT-IT trial (2020), a large international randomized controlled trial that included 12,009 patients with significant upper or lower GI bleeding. This trial found:

• No reduction in death due to bleeding within 5 days (4% in TXA group vs. 4% in placebo group)
• Similar rates of arterial thromboembolic events between groups
• Significantly higher rates of venous thromboembolic events in the TXA group (0.8% vs. 0.4%, RR 1.85) 1

Guidelines Recommendations

Current guidelines do not support routine use of TXA for GI bleeding:

1. British Society of Gastroenterology (2019) explicitly states: "At this time we suggest that use of tranexamic acid in acute LGIB is confined to clinical trials, pending the results of the HALT-IT trial." 2

2. Non-variceal Upper GI Bleeding Guidelines note that while a meta-analysis showed tranexamic acid might reduce surgical intervention and mortality in ulcer bleeding, the quality of evidence was insufficient to recommend it as routine therapy. 2

3. Association of Anaesthetists Guidelines (2025) discuss management of GI bleeding but do not include TXA in their recommendations for either upper or lower GI bleeding management. 2

Management Algorithm for GI Bleeding

Initial Management

1. Resuscitation and stabilization:

   • Fluid resuscitation if hemodynamically unstable
   • Transfusion support with restrictive strategy (Hb threshold of 70 g/L, target 70-100 g/L) 2
   • Higher threshold for patients with cardiovascular disease

2. Risk stratification:

   • Assess shock index (heart rate/systolic BP)
   • If shock index >1 after initial resuscitation or active bleeding is suspected, proceed to CT angiography 2

Diagnostic Approach

• Hemodynamically unstable patients: CT angiography provides the fastest means to localize bleeding 2
• Stabilized patients: Endoscopy (upper or lower depending on suspected source)
• Suspected upper GI source: Consider immediate upper endoscopy if no source identified by initial CTA 2

Therapeutic Options

1. Endoscopic therapy for identified bleeding sources
2. Pharmacological therapy:
   • High-dose proton pump inhibitors for upper GI bleeding (80 mg omeprazole stat followed by 8 mg/hr for 72 hours) 2
   • Terlipressin for suspected cirrhosis/variceal bleeding 2
3. Interventional radiology for cases not amenable to endoscopic control
4. Surgery for uncontrolled hemorrhage despite other measures

Special Considerations

Anticoagulated Patients

• For patients on direct oral anticoagulants (DOACs):
  • Interrupt DOAC therapy at presentation
  • Consider reversal agents (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) for life-threatening hemorrhage
  • Consider restarting anticoagulation approximately 7 days after hemorrhage 2

Common Pitfalls to Avoid

1. Overuse of blood products: Nearly one-third of patients with lower GI bleeding receive RBC transfusions, but up to 80% may be unnecessary 2

2. Delaying endoscopy: Timely access to endoscopy is crucial for diagnosis and treatment

3. Using TXA routinely: Despite earlier smaller studies suggesting benefit, the definitive HALT-IT trial showed no mortality benefit and potential harm from venous thromboembolism 1

4. Failing to identify the source: If initial investigations don't identify the bleeding source, consider repeat endoscopy or alternative imaging modalities

While some case reports suggest TXA may be beneficial in specific scenarios such as Jehovah's Witness patients who refuse blood products 3, the high-quality evidence from the HALT-IT trial should guide standard practice for most patients with GI bleeding.