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

Tranexamic Acid for GI Bleeding: Efficacy and Recommendations

Tranexamic acid (TXA) is not recommended for routine use in GI bleeding as it does not reduce mortality and may increase thromboembolic events, particularly at high doses. While it may reduce rebleeding rates in specific scenarios, current guidelines suggest limiting its use to clinical trials or specific patient populations.

Evidence on TXA in GI Bleeding

High-Dose IV TXA (≥4g/24h)

• Not recommended due to:
  • No mortality benefit (RR 0.98,95% CI 0.88-1.09) 1
  • No significant reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 1
  • Increased risk of thromboembolic events:
    • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
    • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
    • Seizures (RR 1.73,95% CI 1.03-2.93) 1

Low-Dose IV/Enteral TXA

• Mixed evidence:
  • May reduce rebleeding (RR 0.5,95% CI 0.33-0.75) 2
  • May reduce need for surgery (RR 0.58,95% CI 0.38-0.88) 2
  • No definitive mortality benefit (RR 0.62,95% CI 0.36-1.09) 2
  • Insufficient safety data regarding thromboembolic events 1

Guideline Recommendations

The British Society of Gastroenterology (2019) suggests that:

• Use of TXA in acute lower GI bleeding should be confined to clinical trials 1
• They were awaiting results from the HALT-IT trial (now completed, showing no benefit)

The European Society of Intensive Care Medicine (2021) recommends:

• Against using high-dose IV TXA in critically ill patients with GI bleeding (conditional recommendation, high certainty evidence) 1
• Makes no recommendation regarding low-dose IV or enteral TXA due to insufficient evidence 1

Special Populations

TXA may be considered in specific scenarios:

• Patients with hereditary hemorrhagic telangiectasia with mild GI bleeding 1
• Jehovah's Witness patients who refuse blood products (case report evidence) 3

Clinical Decision Algorithm

1. For most patients with GI bleeding:

   • Do not administer high-dose IV TXA
   • Focus on standard management:
     • Resuscitation
     • Endoscopic intervention
     • Correction of coagulopathy if present

2. Consider TXA only in:

   • Clinical trial settings
   • Patients who refuse blood products
   • Patients with hereditary hemorrhagic telangiectasia
   • As rescue therapy in refractory hemorrhage when other options have failed

3. If using TXA, prefer low-dose regimens:

   • Starting at 500mg twice daily, potentially increasing to 1000mg four times daily 1
   • Monitor for thromboembolic complications

Important Caveats

• The HALT-IT trial (largest RCT) showed no mortality benefit and increased thromboembolic events with high-dose TXA 1, 2
• TXA should be given early if used (within 3 hours of bleeding onset) based on trauma literature 1
• TXA has shown benefit in trauma, postpartum hemorrhage, and epistaxis, but evidence for GI bleeding is less compelling 1
• Patients on anticoagulants may have different risk-benefit profiles - consider individual thrombotic risk 1

In summary, while TXA has theoretical benefits in stopping GI bleeding through its antifibrinolytic properties, current high-quality evidence does not support its routine use outside of specific clinical scenarios.