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

Tranexamic Acid for Gastrointestinal Bleeding

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

Evidence Assessment

Efficacy in GI Bleeding

• The HALT-IT trial (2020), the largest and most recent randomized controlled trial on this topic, found that TXA did not reduce death due to bleeding within 5 days compared to placebo (4% vs 4%, RR 0.99,95% CI 0.82-1.18) 1
• While older meta-analyses suggested potential benefits, these were based on smaller, methodologically weaker studies 2, 3
• Current guidelines do not recommend TXA for routine management of GI bleeding:
  • The British Society of Gastroenterology suggests that TXA use in acute lower GI bleeding should be confined to clinical trials only 4
  • Guidelines on non-variceal upper GI hemorrhage state that "further studies of tranexamic acid are necessary before it can be recommended as routine therapy" 5

Safety Concerns

• The HALT-IT trial found that venous thromboembolic events (DVT or PE) were significantly higher in the TXA group compared to placebo (0.8% vs 0.4%, RR 1.85,95% CI 1.15 to 2.98) 1
• This risk of thromboembolism must be weighed against any potential benefits

Current Recommended Approach for GI Bleeding

Initial Management

1. Hemodynamic stabilization:

   • Fluid resuscitation for unstable patients
   • Blood transfusion with a threshold of 70 g/L and target hemoglobin of 70-100 g/L 4
   • Higher transfusion threshold for patients with cardiovascular disease 4

2. Pharmacological management:

   • High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hour for 72 hours) is recommended following successful endoscopic therapy for ulcer bleeding 5
   • Consider interruption and potential reversal of anticoagulants in severe bleeding 4

3. Diagnostic procedures:

   • CT angiography for hemodynamically unstable patients or those with shock index >1 4
   • Endoscopy to identify and potentially treat bleeding source 5

Interventional Management

• Endoscopic therapy for identified bleeding sources
• Repeat endoscopy for rebleeding after initial period of clinical stability 5
• Consider surgical intervention for uncontrolled hemorrhage that cannot be stopped by endoscopic means 5

Special Circumstances

In rare circumstances, TXA might be considered:

• For patients who refuse blood products (e.g., Jehovah's Witnesses) with life-threatening GI bleeding, TXA has been used successfully in case reports 6
• However, this represents an exceptional use case rather than standard practice

Pitfalls and Caveats

• Do not delay definitive management (endoscopy, surgery) while waiting for TXA to work
• The risk of thromboembolic events with TXA must be considered, especially in patients with risk factors for thrombosis
• Up to 15% of apparent lower GI bleeds originate from upper GI sources, so consider upper endoscopy in hemodynamically unstable patients 4

In conclusion, current evidence does not support routine use of TXA for GI bleeding management, and treatment should focus on established approaches including hemodynamic stabilization, endoscopic intervention, and appropriate use of proton pump inhibitors.