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

Tranexamic Acid for GI Bleeding

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding based on high-certainty evidence. 1

Evidence Against Routine TXA Use in GI Bleeding

The European Association for the Study of the Liver and European Society of Intensive Care Medicine recommend against routine TXA use in gastrointestinal bleeding based on high-certainty evidence 1. This recommendation is supported by the HALT-IT trial, a large randomized controlled trial that found:

• High-dose IV TXA did not reduce mortality (RR 0.98,95% CI 0.88-1.09) 2
• TXA did not reduce bleeding outcomes (RR 0.92,95% CI 0.82-1.04) 2
• TXA increased risk of adverse events including:
  • Deep vein thrombosis (RR 2.01,95% CI 1.08-3.72) 2
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 2
  • Seizures (RR 1.73,95% CI 1.03-2.93) 2

Conflicting Evidence

There is some conflicting evidence regarding TXA's effectiveness in GI bleeding:

• Low-dose IV/enteral TXA may reduce:

  • Risk of rebleeding (RR 0.5,95% CI 0.33-0.75) 2
  • Need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 2

• A 2021 meta-analysis suggested TXA reduced:

  • Continued bleeding (RR 0.60,95% CI 0.43-0.84)
  • Need for urgent endoscopic intervention (RR 0.35,95% CI 0.24-0.50)
  • Mortality (RR 0.60,95% CI 0.45-0.80) 3

However, the most recent and highest quality evidence from the HALT-IT trial (which included 12,009 patients) found no benefit and increased harm with high-dose TXA 4.

Recommended Management for GI Bleeding

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

1. Endoscopic therapy as first-line treatment
2. High-dose proton pump inhibitor therapy (80 mg stat followed by 8 mg/hr infusion for 72 hours) following successful endoscopic therapy 1
3. Vasoactive medications for variceal bleeding 1
4. Restrictive blood transfusion strategy (transfuse when Hb <7 g/dl with target 7-9 g/dl) 1
5. Radiological intervention (angiographic embolization) for persistent bleeding not amenable to endoscopic control 1
6. Surgical intervention if endoscopic therapy fails 1

Important Caveats

• If TXA is used despite recommendations against routine use, it should be administered early (within 3 hours of bleeding onset) as studies in trauma have shown that treatment after 3 hours may increase mortality risk 1
• The trend of TXA use in upper GI bleeding has declined between 2010 and 2013 5, likely reflecting emerging evidence against its routine use
• TXA appears to be more often prescribed to patients with more severe GI bleeding 5, but this practice is not supported by current evidence

In summary, current guidelines and high-quality evidence do not support the routine use of TXA to stop GI bleeding, and alternative management strategies should be prioritized.