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

Tranexamic Acid for GI Bleeding: Evidence-Based Recommendations

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 Summary

The most recent and highest quality evidence strongly advises against using TXA for GI bleeding:

• The European Association for the Study of the Liver (EASL) and European Society of Intensive Care Medicine recommend against routine TXA use in GI bleeding 1
• High-certainty evidence shows no reduction in mortality with high-dose IV TXA (RR 0.98,95% CI 0.88-1.09) 1, 2
• TXA increases risk of adverse events including:
  • Deep vein thrombosis (RR 2.01,95% 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, 2

The HALT-IT Trial: Definitive Evidence

The HALT-IT trial, one of the largest randomized trials in GI bleeding (n=12,009), conclusively demonstrated:

• No reduction in death due to bleeding within 5 days (4% in TXA group vs. 4% in placebo group; RR 0.99,95% CI 0.82-1.18) 3
• Higher risk of venous thromboembolic events with TXA (0.8% vs. 0.4%; RR 1.85,95% CI 1.15-2.98) 3
• Based on these findings, the authors concluded: "tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomized trial" 3

Alternative Management Approaches for GI Bleeding

Instead of TXA, focus on:

1. Resuscitation and hemodynamic stabilization:

   • Target hemoglobin level of 70-90 g/L
   • Restrictive packed red blood cell transfusion strategy (transfuse when Hb <7 g/dl with target 7-9 g/dl) 1

2. Early endoscopic intervention:

   • Prompt endoscopy for diagnosis and potential therapeutic intervention

3. For portal hypertension-related bleeding:

   • Use portal hypertension-lowering measures as primary approach
   • Consider coagulopathy correction only if bleeding persists 1

Important Caveats

• While older, smaller meta-analyses suggested potential benefits of low-dose/enteral TXA in reducing rebleeding (RR 0.5,95% CI 0.33-0.75) and need for surgery (RR 0.58,95% CI 0.38-0.88) 2, these findings are limited by imprecision and lack of data on potential harms
• The HALT-IT trial provides the most definitive evidence to date and should guide clinical practice

Common Pitfalls to Avoid

• Don't rely on older, smaller studies suggesting TXA benefit in GI bleeding
• Don't assume that TXA's effectiveness in trauma and surgical bleeding translates to GI bleeding
• Don't overlook the increased risk of thromboembolism and seizures with TXA use in GI bleeding
• Don't delay endoscopic intervention while trying medical management with TXA

In conclusion, current high-quality evidence does not support the use of TXA for GI bleeding, and it may increase harm through thromboembolic events and seizures. Focus instead on prompt resuscitation, early endoscopic intervention, and targeted management based on the underlying cause of bleeding.