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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding, particularly high-dose intravenous TXA, as it shows no mortality benefit while increasing the risk of thrombotic events and seizures. 1

Evidence on TXA in GI Bleeding

High-Dose IV TXA (≥4g/24h)

• Not recommended due to:
  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1
  • No significant 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 risk of adverse events:
    • 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

• Evidence is inconclusive but shows:
  • 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 mortality benefit (RR 0.62,95% CI 0.36-1.09) - not statistically significant 1
  • Limited data on adverse events 1

Current Guideline Recommendations

The British Society of Gastroenterology (2019) recommends that:

• Use of TXA in acute lower GI bleeding should be confined to clinical trials 1
• Current evidence is considered historic and may not be applicable to modern care with high-dose acid suppression and endoscopic therapy 1

The European Society of Intensive Care Medicine (2021) makes:

• A conditional recommendation against using high-dose IV TXA in GI bleeding 1
• No recommendation regarding low-dose IV or enteral TXA due to insufficient evidence 1

Special Considerations

Upper vs. Lower GI Bleeding

• Most research has focused on upper GI bleeding 2
• A recent study (2024) found no significant effect of TXA on blood transfusion requirements in lower GI bleeding 3

Dialysis Patients

• Limited evidence suggests TXA may be beneficial as adjunctive therapy in dialysis patients with upper GI bleeding 4
• In this specific population, TXA was associated with decreased early rebleeding and reduced need for blood transfusions 4

Common Pitfalls and Caveats

1. Timing matters: The benefit of TXA appears to diminish with delayed administration; most effective within 3 hours of bleeding onset 5

2. Dose-dependent risks: Higher doses of TXA (≥4g/24h) increase thrombotic risks without improving outcomes 1, 6

3. Patient selection: TXA should be used with caution in patients with:

   • Cardiovascular disease
   • Renal dysfunction (requires dose adjustment)
   • History of seizures
   • Disseminated intravascular coagulation (DIC) 5

4. Monitoring: If TXA is used, monitor for:

   • Clinical signs of thrombosis
   • Renal function
   • Neurological symptoms (seizure risk) 5

Alternative First-Line Approaches for GI Bleeding

Instead of TXA, current guidelines recommend:

• For suspected variceal bleeding: terlipressin as first-line pharmacological therapy 5
• For non-variceal bleeding: high-dose proton pump inhibitor (80 mg stat followed by 8 mg/hr infusion for 72 hours) 5
• Early endoscopic intervention for diagnosis and treatment 5

In conclusion, while TXA has shown benefits in other bleeding conditions, current high-quality evidence does not support its routine use in GI bleeding, particularly at high doses. Management should focus on established interventions including endoscopic therapy, acid suppression for upper GI bleeding, and appropriate resuscitation.