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

Tranexamic Acid (TXA) for Gastrointestinal Bleeding

Tranexamic acid should not be used for the treatment of gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1, 2, 3

Evidence Against High-Dose IV TXA

High-dose intravenous TXA (≥4g/24h) has been thoroughly evaluated in gastrointestinal bleeding with high-certainty evidence showing:

• No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1, 2
• No significant reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 1, 2
• No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1, 2

More concerning, high-dose TXA is associated with increased risks:

• Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1, 2
• Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1, 2
• Seizures (RR 1.73,95% CI 1.03-2.93) 1, 2

The HALT-IT trial, the largest randomized controlled trial on this topic (n=12,009), conclusively demonstrated that high-dose TXA does not reduce death from gastrointestinal bleeding but increases venous thromboembolic events 3.

Low-Dose/Enteral TXA Considerations

While some evidence suggests low-dose IV or enteral TXA may reduce:

• Rebleeding (RR 0.5,95% CI 0.33-0.75) 4
• Need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 4

These findings are limited by:

• Smaller studies with potential bias
• Imprecision in the estimates
• Lack of comprehensive safety data 1, 2

The European Society of Intensive Care Medicine makes no recommendation regarding low-dose IV or enteral TXA due to this uncertainty 1.

Recommended Approach to GI Bleeding

Instead of TXA, focus on evidence-based interventions:

1. Resuscitation and hemodynamic stabilization

   • Target hemoglobin of 70-90 g/L 1
   • Early measures to maintain normothermia 1

2. Early endoscopic intervention

   • Primary method for diagnosis and treatment
   • Timing based on risk stratification

3. Vasoactive medications

   • For suspected variceal bleeding

4. Coagulation management

   • Consider fibrinogen supplementation or FFP if coagulopathy present 1
   • Monitor calcium levels during massive transfusion 1

Special Considerations

• Patients on anticoagulants: Consider withholding the drug and using specific reversal agents for severe bleeding with DOACs 2

• Patients with liver disease: Exercise additional caution due to increased risk of thromboembolic events 2

• Trauma patients: 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 2

Common Pitfalls

1. Assuming TXA benefits extend across all bleeding scenarios: Despite its effectiveness in trauma and surgical bleeding, TXA does not provide mortality benefit in GI bleeding.

2. Underestimating thromboembolic risk: The increased risk of venous thromboembolism with TXA in GI bleeding is significant and should not be overlooked.

3. Delaying definitive treatment: Focusing on TXA administration may delay more effective interventions like endoscopy.