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

Tranexamic Acid for GI Bleeding

Tranexamic acid (TXA) is not recommended as routine therapy for gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1

Evidence Assessment

The most recent and highest quality evidence from the Praxis Medical Insights guidelines (2025) clearly indicates that TXA should not be used routinely for GI bleeding. This recommendation is supported by the HALT-IT trial, a large international randomized controlled trial that found TXA did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) but increased the risk of venous thromboembolic events (RR 1.85,95% CI 1.15-2.98) compared to placebo 2.

Clinical Decision Algorithm

1. Initial assessment of GI bleeding:

   • For hemodynamically unstable patients, prioritize CT angiography to localize bleeding 1
   • Use restrictive transfusion threshold of 70 g/L (aiming for 70-100 g/L) 3
   • Consider higher transfusion threshold for patients with cardiovascular disease 3

2. First-line management options (instead of TXA):

   • Endoscopic hemostasis for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) 1
   • High-dose IV proton pump inhibitor therapy following successful endoscopic therapy 1
   • Interventional radiology for ongoing bleeding not responding to endoscopic therapy 1

3. Special circumstances where TXA might be considered:

   • Patients who refuse blood products (e.g., Jehovah's Witnesses) 4
   • As a temporizing measure while awaiting definitive intervention when other options are unavailable
   • Note: Even in these cases, the risk of thromboembolic events must be carefully weighed

Contraindications to TXA

• Absolute contraindications: Recent thrombosis 1
• Relative contraindications: Atrial fibrillation, known thrombophilia 1
• Specific contraindication: Cirrhosis and variceal bleeding due to increased thromboembolic risk 1

Key Considerations

• The Association of Anaesthetists guidelines (2025) emphasize the importance of early risk stratification, appropriate transfusion support, and timely access to endoscopy or interventional radiology for GI bleeding management 3
• For patients on direct oral anticoagulants with life-threatening hemorrhage, specific reversal agents like idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors) should be considered rather than TXA 1
• If anticoagulation needs to be restarted, this should occur approximately 7 days after hemorrhage if the bleeding source has been controlled 1

While some older, smaller studies suggested potential benefits of TXA in GI bleeding 5, 6, the most recent and highest quality evidence from the HALT-IT trial and current guidelines clearly demonstrate that TXA does not improve mortality in GI bleeding and increases thromboembolic risk, making it an inappropriate choice for routine management of GI bleeding.