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 as it does not reduce mortality and may increase thromboembolic events.

Current Evidence on TXA in GI Bleeding

High-Dose IV TXA (24-hour infusion protocol)

• The most recent high-quality evidence from the HALT-IT trial shows that high-dose IV TXA (1g loading dose followed by 3g over 24 hours) does not reduce:

  • Mortality (RR 0.98,95% CI 0.88-1.09) 1
  • Bleeding (RR 0.92,95% CI 0.82-1.04) 1

• High-dose IV TXA significantly increases risk of:

  • Deep vein thrombosis (RR 2.01,95% CI 1.08-3.72) 1
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

Low-Dose/Enteral TXA

• Some evidence suggests low-dose IV or enteral TXA may:
  • Reduce rebleeding (RR 0.5,95% CI 0.33-0.75) 1
  • Reduce need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
  • However, more evidence is needed to establish safety 1

Special Considerations

Portal Hypertension-Related Bleeding

• TXA is strongly contraindicated in patients with cirrhosis and active variceal bleeding 2
• Vasoactive medications (terlipressin, somatostatin, octreotide) are recommended first-line treatments instead 2

Upper vs Lower GI Bleeding

• Current guidelines do not recommend routine use of TXA in either upper or lower GI bleeding 3
• For lower GI bleeding, the British Society of Gastroenterology specifically suggests that TXA use should be confined to clinical trials 3

Recommended Management Algorithm for GI Bleeding

1. Initial Resuscitation

   • Fluid resuscitation if hemodynamically unstable 3
   • Restrictive transfusion strategy (transfuse when Hb <70 g/L, target 70-100 g/L) 3
   • Higher threshold (80-100 g/L) for patients with cardiovascular disease 3

2. First-Line Pharmacological Therapy

   • For suspected variceal bleeding: terlipressin 3, 2
   • For non-variceal bleeding: high-dose proton pump inhibitor (80 mg stat followed by 8 mg/hr infusion for 72 hours) 3

3. Endoscopic Intervention

   • Timely access to endoscopy for diagnosis and treatment 3
   • Endoscopic therapy based on bleeding source 3

4. Management of Rebleeding

   • Repeat endoscopy to confirm rebleeding and attempt endoscopic therapy again 3
   • Consider interventional radiology for persistent bleeding not amenable to endoscopic control 3
   • Consider surgery if endoscopic therapy fails 2

Common Pitfalls and Caveats

• Despite some older meta-analyses suggesting benefit 4, the most recent and highest quality evidence does not support routine use of TXA in GI bleeding 1, 5
• TXA should not be used as a substitute for definitive treatment (endoscopic, radiological, or surgical intervention)
• TXA may have a role in specific scenarios (e.g., patients who refuse blood products 6), but this should be considered on a case-by-case basis
• The timing of TXA administration appears critical in other bleeding conditions (trauma, postpartum hemorrhage), but this has not been established for GI bleeding

In conclusion, current evidence and guidelines do not support the routine use of TXA for GI bleeding. Management should focus on appropriate resuscitation, endoscopic intervention, and condition-specific pharmacological therapy.