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 in GI Bleeding

The European Society of Intensive Care Medicine makes a clear recommendation against using high-dose intravenous TXA in patients with gastrointestinal bleeding based on high-certainty evidence 1. This recommendation is supported by multiple lines of evidence:

• High-dose intravenous TXA (≥4g/24h) shows no reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1
• TXA is associated with significant 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, a large international randomized controlled trial published in 2020, conclusively demonstrated that tranexamic acid 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 on Low-Dose TXA

While high-dose IV TXA is not recommended, there is some conflicting evidence regarding low-dose or enteral TXA:

• 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) 1, 3
• However, these results are limited by imprecision and lack of data on potential harms 1
• The European Society of Intensive Care Medicine makes no recommendation regarding low-dose IV or enteral TXA due to this uncertainty 1

Recommended Approaches for GI Bleeding Management

Instead of TXA, the following evidence-based interventions are recommended for GI bleeding:

1. Resuscitation and hemodynamic stabilization:

   • Target hemoglobin of 70-90 g/L 1
   • Maintain normothermia 1

2. Early endoscopic intervention for diagnosis and treatment 1

3. For variceal bleeding:

   • Prompt initiation of vasoactive therapy and antibiotics 1
   • Portal hypertension-lowering measures as primary approach 1
   • Correction of coagulopathy only on case-by-case basis if bleeding persists 1

4. 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

5. For coagulopathy:

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

Special Considerations

• In patients with liver disease, TXA should be avoided due to increased risk of thromboembolic events 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
• 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

Common Pitfalls to Avoid

1. Don't be misled by older, smaller studies: Some older meta-analyses of small trials suggested TXA might be beneficial 4, but these have been superseded by larger, more recent trials showing no benefit and potential harm 2

2. Don't extrapolate from trauma literature: Although TXA is effective for trauma bleeding, this benefit does not extend to GI bleeding 1

3. Don't use TXA as a substitute for definitive treatment: Early endoscopic intervention remains the cornerstone of management for GI bleeding 1