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

Tranexamic Acid for Gastrointestinal Bleeding

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

Evidence Against TXA Use in GI Bleeding

The most recent and highest quality evidence strongly advises against using TXA for 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
• The European Association for the Study of the Liver (EASL) and the American College of Physicians recommend against TXA use in patients with cirrhosis and active variceal bleeding, as well as in general upper GI bleeding 1
• The HALT-IT trial, a large international randomized controlled trial with 12,009 patients, found that TXA did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) 2
• High-dose intravenous TXA (≥4g/24h) showed no reduction in mortality (RR 0.98,95% CI 0.88-1.09) with high-certainty evidence 1

Risks Associated with TXA in GI Bleeding

TXA use in GI bleeding is associated with significant adverse events:

• Increased risk of deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
• Increased risk of pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
• Increased risk of seizures (RR 1.73,95% CI 1.03-2.93) 1
• The HALT-IT trial specifically found higher venous thromboembolic events with TXA compared to placebo (RR 1.85; 95% CI 1.15 to 2.98) 2

Contrasting Evidence

Some older and smaller studies suggested potential benefits:

• Low-dose IV or enteral TXA may 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), but these results are limited by imprecision 1, 3
• Some meta-analyses of smaller trials suggested TXA might decrease rebleeding rates in upper GI bleeding (RR 0.64,95% CI 0.47-0.86) 4

However, these potential benefits are outweighed by the lack of mortality benefit and increased thromboembolic risks demonstrated in larger, more recent trials.

Recommended Approach for GI Bleeding Management

Instead of TXA, the following evidence-based interventions should be prioritized:

1. Resuscitation with target hemoglobin of 70-90 g/L 1
2. Maintain normothermia during resuscitation 1
3. Early endoscopic intervention 1
4. For variceal bleeding: prompt initiation of vasoactive therapy, antibiotics, and endoscopic band ligation 1
5. For patients on anticoagulants: withhold the drug, resuscitate, and consider specific reversal agents for severe bleeding with DOACs 1

Important Distinction from Trauma Use

While TXA has proven benefits in trauma patients with bleeding when administered within 3 hours of injury 5, this benefit does not extend to GI bleeding 1. The pathophysiology and management of traumatic hemorrhage differs significantly from GI bleeding.

Monitoring if TXA is Used (Not Recommended)

If TXA is used despite recommendations against it (which is not advised), careful monitoring for adverse events is essential, including:

• Thromboembolic complications
• Seizures
• Timing of administration (benefits in trauma are only seen within 3 hours of injury)

The evidence clearly shows that TXA should not be used in the management of GI bleeding due to lack of mortality benefit and increased risk of harm.