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

Tranexamic Acid for GI Bleeding: Evidence-Based Recommendations

High-dose intravenous tranexamic acid (TXA) should not be used for gastrointestinal bleeding as it shows no benefit in reducing mortality or rebleeding while increasing the risk of thrombotic events and seizures. 1

Current Evidence on TXA in GI Bleeding

High-Dose IV TXA (≥4g/24h)

• Not recommended based on high-certainty evidence 1
• Evidence from five studies, including the large HALT-IT trial, shows:
  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1
  • No reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 1
  • No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• Increased adverse events:
  • Higher rates of deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
  • Higher rates of pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
  • Increased risk of seizures (RR 1.73,95% CI 1.03-2.93) 1

Low-Dose IV/Enteral TXA

• No definitive recommendation due to moderate-certainty evidence 1
• Some potential benefits observed:
  • Possible reduction in rebleeding (RR 0.5,95% CI 0.38-0.88) 1
  • Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
  • Possible trend toward reduced mortality (RR 0.62,95% CI 0.36-1.09) 1
• Limitations: smaller studies with imprecise results and inadequate reporting of adverse events 1

Special Considerations for Different Types of GI Bleeding

Variceal Bleeding

• TXA is specifically contraindicated in variceal bleeding 1
• Strong recommendation against use (Level of Evidence 2) 1
• A large randomized placebo-controlled trial showed:
  • No beneficial effect of TXA in suspected variceal bleeding 1
  • Almost 2-fold increase in venous thromboembolic events in patients with liver disease/suspected variceal bleeding 1
• Possible explanations:
  • Limited role of hemostasis in variceal bleeding 1
  • Frequent hypofibrinolytic state in critically ill cirrhotic patients 1

Lower GI Bleeding

• Recent evidence (2024) shows no significant effect on blood transfusion requirements in lower GI bleeding 2
• The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials 1

Clinical Pitfalls and Caveats

1. Thrombotic risk: The increased risk of thrombotic events with high-dose TXA is particularly concerning in patients with liver disease 1

2. Portal pressure considerations: In cirrhotic patients, administration of blood products can increase portal pressure, potentially worsening bleeding outcomes 1

3. Timing matters: If considering TXA for other indications (not GI bleeding), early administration (within 3 hours of bleeding onset) appears most beneficial 1

4. Dose-dependent effects: The adverse effects of TXA appear to be dose-related, with high-dose regimens showing more harm than benefit 1

5. Alternative approaches: For GI bleeding, focus should remain on established treatments:

   • Prompt endoscopic intervention
   • Vasoactive drugs for variceal bleeding
   • Portal hypertension-lowering measures for portal hypertensive bleeding 1

In conclusion, while TXA has proven beneficial in other bleeding conditions like trauma and postpartum hemorrhage, current high-quality evidence does not support its use in GI bleeding, particularly at high doses. For variceal bleeding, TXA is specifically contraindicated due to increased thrombotic risk.