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

Tranexamic Acid for GI 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 Assessment

The most recent and highest quality evidence strongly advises against routine use of TXA for GI bleeding:

• The European Association for the Study of the Liver (EASL) and European Society of Intensive Care Medicine explicitly recommend against TXA use in GI bleeding 1
• The HALT-IT trial, a large international randomized controlled trial with 12,009 patients, found that high-dose IV TXA:
  • Did not reduce death from gastrointestinal bleeding (RR 0.99,95% CI 0.82-1.18) 2
  • Increased risk of venous thromboembolic events (RR 1.85,95% CI 1.15-2.98) 2
  • Showed no benefit in reducing arterial thromboembolic events 2

Dosing Considerations

While high-dose IV TXA (1g loading dose followed by 3g over 24 hours) has been clearly shown to be ineffective and potentially harmful for GI bleeding, there is some limited evidence regarding lower doses:

• Low-dose IV or enteral TXA may reduce:
  • Risk of rebleeding (RR 0.5,95% CI 0.33-0.75) 3
  • Need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 3
• However, this data is limited by imprecision and lack of comprehensive safety data 1

Risks of TXA in GI Bleeding

High-dose IV TXA increases the risk of:

• Deep vein thrombosis (RR 2.01,95% CI 1.08-3.72) 3
• Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 3
• Seizures (RR 1.73,95% CI 1.03-2.93) 3

Alternative Management Approaches

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

1. Resuscitation and hemodynamic stabilization:

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

2. For portal hypertension-related bleeding:

   • Portal hypertension-lowering measures are the primary approach 1
   • Correction of coagulopathy only on case-by-case basis if bleeding persists 1

3. Early endoscopic intervention for diagnosis and treatment 1

4. Vasoactive medications as appropriate for the cause of bleeding 1

Special Considerations

• In patients with cirrhosis, transfusion of blood products can increase portal pressure, potentially worsening bleeding 1
• For patients on anticoagulants with GI bleeding:
  • Withhold the anticoagulant
  • Resuscitate the patient
  • Consider specific reversal agents for severe bleeding with DOACs 1

Conclusion

Despite some older or smaller studies suggesting potential benefits, the highest quality and most recent evidence clearly demonstrates that TXA does not improve mortality in GI bleeding and increases thromboembolic complications. Therefore, TXA should not be used for GI bleeding management outside of clinical trials.