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

Tranexamic Acid for GI Bleeding: Current Evidence and Recommendations

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding as it does not reduce mortality or rebleeding rates and may increase thromboembolic complications. 1

Evidence Summary

High-Dose IV TXA in GI Bleeding

Current high-quality evidence, including the large HALT-IT trial, demonstrates that high-dose IV TXA (4g/24h or greater) provides:

• No reduction in mortality (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
• No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1

More concerning is the increased risk of adverse 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/Enteral TXA

Some evidence suggests potential benefits with low-dose IV or enteral TXA:

• Possible reduction in rebleeding (RR 0.5,95% CI 0.38-0.88) 1
• Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1

However, these findings are limited by imprecision and small study sizes, with insufficient data on potential harms 1.

Special Considerations for Patients with Liver Disease

In patients with cirrhosis and suspected variceal bleeding:

• No beneficial effect of TXA has been observed 1
• Almost 2-fold increase in venous thromboembolic events was observed in the TXA group compared to placebo 1
• The limited efficacy may be due to the limited role of hemostasis in variceal bleeding and the frequent occurrence of hypofibrinolytic state in critically ill cirrhotic patients 1

Management Approach for GI Bleeding

1. First-line management:

   • Focus on resuscitation, hemodynamic stabilization
   • Early endoscopic intervention for diagnosis and treatment
   • Vasoactive medications for suspected variceal bleeding

2. For portal hypertension-related bleeding:

   • Portal hypertension-lowering measures should be the primary approach 1
   • Correction of coagulopathy should be considered only on a case-by-case basis if bleeding persists 1

3. For patients on anticoagulants:

   • In most cases, withhold the drug, resuscitate the patient, and wait for anticoagulant effects to dissipate 1
   • For severe bleeding with DOACs, consider specific reversal agents (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) 1

Pitfalls and Caveats

1. Avoid routine use of TXA in GI bleeding

   • Despite its effectiveness in trauma and surgical bleeding, high-dose IV TXA does not show benefit in GI bleeding

2. Be cautious in patients with liver disease

   • Increased risk of thromboembolic events in cirrhotic patients receiving TXA 1

3. Consider the etiology of bleeding

   • TXA may have different effects depending on the cause of bleeding
   • Portal hypertension-related bleeding should be managed primarily with portal pressure-reducing strategies 1

4. Monitor for adverse events if TXA is used

   • Vigilance for thromboembolic complications (DVT, PE)
   • Monitor for seizures, particularly with high-dose regimens

While some older and smaller studies suggested benefits of TXA in GI bleeding 2, 3, 4, the most recent and highest quality evidence, particularly from the HALT-IT trial, does not support its routine use 1, 5. Current guidelines recommend against the use of high-dose IV TXA in GI bleeding, with no clear recommendation for low-dose or enteral formulations pending further research 1.