Tranexamic Acid for GI Bleeding
Tranexamic acid (TXA) should not be used for the treatment of gastrointestinal bleeding as it does not reduce mortality from GI bleeding and may increase the risk of venous thromboembolic events. 1
Evidence on TXA for GI Bleeding
Current Guidelines Recommendations
The most recent and high-quality evidence from guidelines indicates that tranexamic acid is not recommended for routine use in gastrointestinal bleeding:
The 2019 British Society of Gastroenterology guidelines state that "use of tranexamic acid in acute LGIB is confined to clinical trials" and should not be used in routine clinical practice for lower GI bleeding. 2
For upper GI bleeding, older guidelines (2002) noted that while a meta-analysis showed tranexamic acid might reduce surgical intervention and tend to reduce mortality, further studies were necessary before it could be recommended as routine therapy. 2
Definitive Clinical Trial Results
The HALT-IT trial (2020), which is the largest and most recent randomized controlled trial on this topic, provides the strongest evidence:
- This international, multicenter trial included 12,009 patients with significant upper or lower GI bleeding
- TXA did not reduce death due to bleeding within 5 days (4% in TXA group vs. 4% in placebo group)
- Venous thromboembolic events were significantly higher in the TXA group (0.8% vs. 0.4%, RR 1.85)
- The authors concluded that "tranexamic acid should not be used for the treatment of gastrointestinal bleeding" 1
Conflicting Evidence
Some earlier, smaller studies suggested potential benefits:
A 2021 meta-analysis of 13 randomized trials (n=2,271) found that TXA significantly reduced continued bleeding (RR=0.60), urgent endoscopic intervention (RR=0.35), and mortality (RR=0.60) compared to placebo 3
A 2015 review concluded that TXA probably decreases rebleeding and mortality without increasing thromboembolic events 4
However, these findings are superseded by the HALT-IT trial, which was specifically designed to provide definitive evidence on this question and included more patients than all previous trials combined.
Special Considerations
Trauma vs. GI Bleeding
It's important to note that while TXA is effective for trauma-related bleeding, this doesn't extend to GI bleeding:
The European guideline on management of major bleeding following trauma (2023) strongly recommends TXA for trauma patients who are bleeding or at risk of significant bleeding 2
However, the pathophysiology of traumatic bleeding differs from GI bleeding, explaining the different outcomes
Case Reports
There are isolated case reports of successful TXA use in specific scenarios, such as in Jehovah's Witness patients who refuse blood products 5, but these do not override the high-quality evidence from large randomized trials.
Clinical Management of GI Bleeding
For GI bleeding management, focus instead on:
- Resuscitation and hemodynamic stabilization
- Proton pump inhibitor therapy (for upper GI bleeding)
- Early endoscopic intervention for diagnosis and treatment
- Correction of coagulopathy if present
- Interventional radiology or surgery for refractory bleeding
Pitfalls to Avoid
- Don't use TXA routinely for GI bleeding based on its success in trauma settings
- Don't delay definitive endoscopic therapy while trying medical management
- Be aware of the increased risk of venous thromboembolism with TXA in GI bleeding patients
- Don't extrapolate from older, smaller studies when higher quality evidence is available
The definitive HALT-IT trial provides the strongest evidence that TXA should not be used for GI bleeding management in routine clinical practice.