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 due to lack of benefit and increased risk of thrombotic events. 1

Current Evidence on TXA for GI Bleeding

High-Dose IV TXA (≥4g/24h)

• Not Recommended: Strong evidence shows no benefit with potential harm
• Based on multiple studies including the large HALT-IT trial 1
• No difference in:
  • Mortality (RR 0.98,95% CI 0.88-1.09) 1
  • Rebleeding rates (RR 0.92,95% CI 0.82-1.04) 1
  • Need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• Increased risks:
  • Deep vein thrombosis (RR 2.10,95% 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 IV/Enteral TXA

• No definitive recommendation: Evidence suggests possible benefit but is limited
• Moderate certainty evidence shows:
  • Reduced rebleeding (RR 0.5,95% CI 0.38-0.88) 1
  • Reduced need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
  • Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09) 1
• Limited data on potential adverse events in these studies 1

Special Considerations for Different GI Bleeding Types

Variceal Bleeding

• TXA should not be used for variceal bleeding 1
• Strong recommendation based on high-quality evidence 1
• Reasons for ineffectiveness:
  • Limited role of hemostasis in variceal bleeding 1
  • Frequent hypofibrinolytic state in critically ill cirrhotic patients 1
  • Increased risk of thrombotic events in patients with liver disease 1

Lower GI Bleeding

• Recent evidence shows no benefit for TXA in lower GI bleeding 2
• A 2024 randomized controlled trial found:
  • No difference in blood transfusion requirements between TXA and placebo groups 2
  • No reduction in units of packed red blood cells transfused 2

Alternative Management Approaches

For GI bleeding, focus on established effective treatments:

• Prompt endoscopic intervention 1
• Vasoactive medications for variceal bleeding 1
• Portal hypertension-lowering measures for portal hypertensive gastropathy 1
• Restrictive blood transfusion strategy to avoid increasing portal pressure 1

Clinical Pitfalls to Avoid

1. Inappropriate use of TXA in variceal bleeding: May increase thrombotic risk without benefit 1

2. Relying on TXA instead of definitive treatment: Endoscopic intervention remains the cornerstone of management 1

3. Using high-dose IV TXA protocols: These increase thrombotic risk without improving outcomes 1

4. Delaying appropriate care: Focus on rapid assessment, resuscitation, and definitive intervention rather than adjunctive medications with limited evidence 1

5. Overlooking the cause-specific approach: Management should be tailored to the specific cause of bleeding (variceal vs. non-variceal, upper vs. lower) 1

While some older or smaller studies suggested benefit for TXA in GI bleeding 3, 4, the most recent high-quality evidence, particularly from large randomized trials, does not support its routine use, especially at high doses.