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

Tranexamic Acid (TXA) for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for gastrointestinal bleeding as it does not effectively stop GI bleeds and increases the risk of thromboembolic events. 1

Evidence Against TXA in GI Bleeding

The evidence strongly advises against using TXA for GI bleeding:

• High-dose IV TXA (≥4g/24h) shows:

  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 2
  • No significant reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 2
  • No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 2

• Increased risks with TXA use include:

  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 2
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 2
  • Seizures (RR 1.73,95% CI 1.03-2.93) 2

The European Society of Intensive Care Medicine makes a conditional recommendation against using high-dose IV TXA in critically ill patients with gastrointestinal bleeding, based on high-certainty evidence 2. Similarly, the European Association for the Study of the Liver (EASL) and the American College of Physicians recommend against TXA use in patients with GI bleeding 1.

Low-Dose/Enteral TXA Considerations

While some smaller studies suggest low-dose IV or enteral TXA might reduce rebleeding (RR 0.5,95% CI 0.38-0.88) and need for surgical intervention (RR 0.58,95% CI 0.38-0.88), these results are limited by imprecision and lack of data on potential harms 2. The European Society of Intensive Care Medicine makes no recommendation regarding low-dose IV or enteral TXA due to this uncertainty 2.

Special Considerations

• Patients with liver disease: Extra caution is warranted as TXA carries an increased risk of thromboembolic events in this population 1
• Timing: Unlike trauma patients where TXA shows benefit when given within 3 hours of injury, this benefit does not extend to GI bleeding 1

Evidence-Based Alternatives for GI Bleeding Management

Instead of TXA, recommended approaches include:

• For variceal bleeding: Prompt initiation of vasoactive therapy, antibiotics, and endoscopic band ligation 1
• General approach: Resuscitation, hemodynamic stabilization, early endoscopic intervention, and vasoactive medications 1
• For patients on anticoagulants: Withhold the anticoagulant, resuscitate the patient, and consider specific reversal agents for severe bleeding with DOACs 1

Clinical Pitfalls to Avoid

• Do not use TXA based on its benefits in trauma patients - the evidence does not support this extrapolation to GI bleeding
• Do not overlook the increased risk of thromboembolic events when considering TXA, especially in patients with liver disease
• Avoid delaying proven effective interventions (endoscopy, vasoactive medications) while trying unproven therapies like TXA