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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for gastrointestinal bleeding as it does not reduce mortality, does not significantly reduce rebleeding, and increases the risk of thromboembolic events and seizures. 1

Evidence Against TXA Use in GI Bleeding

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 1. This recommendation is supported by the following findings:

• High-dose IV TXA (≥4g/24h) shows:

  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09)
  • No significant reduction in rebleeding (RR 0.92,95% CI 0.82-1.04)
  • No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1

• TXA use is associated with increased risks of:

  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72)
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0)
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

The HALT-IT trial, the largest and most recent randomized controlled trial on this topic, found that TXA did not reduce death from gastrointestinal bleeding but did increase venous thromboembolic events (RR 1.85; 95% CI 1.15 to 2.98) 2.

Conflicting Evidence

Some older and smaller studies suggest potential benefits of TXA:

• A 2021 meta-analysis indicated that TXA significantly reduced continued bleeding (RR = 0.60; 95%CI, 0.43-0.84), urgent endoscopic intervention (RR = 0.35; 95%CI, 0.24-0.50), and mortality (RR = 0.60; 95%CI, 0.45-0.80) compared with placebo 3.

• Low-dose IV or enteral TXA may reduce rebleeding (RR 0.5,95% CI 0.33-0.75) and need for surgery (RR 0.58,95% CI 0.38-0.88), but these results are limited by imprecision and lack of data on potential harms 4.

However, these findings are outweighed by the larger, more recent HALT-IT trial and the resulting guideline recommendations against TXA use.

Recommended Management Approach for GI Bleeding

Instead of TXA, the following approaches are recommended for GI bleeding management:

1. Initial management:

   • Resuscitation and hemodynamic stabilization
   • Early endoscopic intervention
   • Vasoactive medications 1

2. For variceal bleeding:

   • Prompt initiation of vasoactive therapy
   • Antibiotics
   • Endoscopic band ligation
   • Portal hypertension-lowering measures 1

3. For patients on anticoagulants:

   • Withhold the anticoagulant
   • Resuscitate the patient
   • Wait for anticoagulant effects to dissipate
   • Consider specific reversal agents for severe bleeding with DOACs 1

Important Caveats

• While TXA has proven benefits in trauma patients with bleeding when administered within 3 hours of injury, this benefit does not extend to GI bleeding 1.

• In patients with liver disease, there is an increased risk of thromboembolic events with TXA use 1.

• The European Association for the Study of the Liver (EASL) and the American College of Physicians specifically recommend against TXA use in patients with cirrhosis and active variceal bleeding 1.