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

Tranexamic Acid for GI Bleeding

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

Evidence Against Routine TXA Use in GI Bleeding

The most recent and highest quality evidence strongly advises against using tranexamic acid for GI bleeding:

• The Praxis Medical Insights guidelines (2025) explicitly state that TXA is not recommended as routine therapy for GI bleeding due to lack of mortality benefit and increased risk of thromboembolic events 1
• The HALT-IT trial (2020), a large international randomized controlled trial with over 12,000 patients, found that TXA did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) 2
• TXA was associated with a significantly higher risk of venous thromboembolic events compared to placebo (RR 1.85,95% CI 1.15-2.98) 2

Contraindications and Special Considerations

TXA has specific contraindications in certain patient populations with GI bleeding:

• Absolute contraindication in patients with recent thrombosis 1
• Relative contraindications in patients with atrial fibrillation and known thrombophilia 1
• Specifically contraindicated in patients with cirrhosis and variceal bleeding due to increased thromboembolic risk 1

Recommended Management Approach for GI Bleeding

Instead of TXA, the following evidence-based approaches are recommended:

1. Initial assessment and stabilization:

   • Use a restrictive transfusion threshold of 70 g/L (aiming for 70-100 g/L) 3, 1
   • Consider higher transfusion threshold for patients with cardiovascular disease 3, 1

2. Localization of bleeding:

   • For hemodynamically unstable patients or those with shock index >1, perform CT angiography to localize bleeding 3, 1
   • Consider upper endoscopy if brisk rectal bleeding with hemodynamic instability is present 3, 1

3. Therapeutic interventions:

   • Early endoscopy with hemostatic therapy for high-risk stigmata 1
   • High-dose IV proton pump inhibitor therapy following successful endoscopic therapy 1
   • Consider interventional radiology for ongoing bleeding not responding to endoscopic therapy 1

Exceptional Circumstances

While the general recommendation is against TXA use, there may be rare circumstances where it might be considered:

• In Jehovah's Witness patients who refuse blood products, TXA has been used as a last resort 4
• However, even in these cases, the risk of thromboembolic events must be carefully weighed against potential benefits

Conclusion

The current highest quality evidence does not support the use of TXA to stop GI bleeding. The HALT-IT trial, which is the largest and most definitive study on this topic, found no mortality benefit and increased thromboembolic risk. Management should focus on appropriate transfusion strategies, early endoscopy, and other evidence-based interventions as outlined in current guidelines.