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

Tranexamic Acid for Gastrointestinal Bleeding

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. 1

Evidence on TXA in GI Bleeding

High-Dose IV TXA

• The European Society of Intensive Care Medicine (ESICM) guidelines provide a conditional recommendation against using high-dose IV TXA (≥4g/24h) in critically ill patients with GI bleeding 1
• Evidence from five studies, including the large HALT-IT trial, showed:
  • 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 risks were observed for:
  • 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

• ESICM makes no recommendation regarding low-dose IV or enteral TXA due to limited evidence 1
• Seven smaller studies showed potential benefits:
  • Reduction in rebleeding (RR 0.5,95% CI 0.38-0.88) 1
  • Reduction in 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
• However, these results are limited by imprecision and lack of data on potential harms 1

Special Considerations for Specific GI Bleeding Types

Variceal Bleeding

• TXA is specifically contraindicated in variceal bleeding 1
• A large randomized placebo-controlled trial showed no beneficial effect of TXA in suspected variceal bleeding 1
• In patients with cirrhosis and variceal bleeding, TXA should not be used (Level of Evidence 2, strong recommendation) 1
• Patients with liver disease/suspected variceal bleeding showed increased risk of venous thromboembolic events with TXA 1

Lower GI Bleeding

• Recent evidence suggests TXA has no significant effect on blood transfusion requirements in lower GI bleeding 2
• British Society of Gastroenterology guidelines suggest that use of TXA in acute lower GI bleeding should be confined to clinical trials 1

Pitfalls and Caveats

1. Thrombotic Risk: The increased risk of thrombotic events with high-dose TXA must be carefully considered, especially in patients with liver disease 1

2. Timing of Administration: If considering low-dose TXA (which has limited evidence), early administration would be most beneficial, similar to its use in other bleeding conditions 1

3. Underlying Cause: TXA does not address the underlying cause of GI bleeding, which requires specific interventions:

   • For variceal bleeding: vasoactive drugs, antibiotics, and endoscopic band ligation 1
   • For non-variceal bleeding: endoscopic therapy remains the cornerstone of management

4. Portal Hypertension: In cirrhosis patients, administration of blood products can increase portal pressure, potentially worsening bleeding outcomes 1

Conclusion

Based on current high-quality evidence, TXA does not stop GI bleeding and should not be routinely used for this indication, particularly at high doses. Standard management with endoscopic therapy, acid suppression (for upper GI bleeding), and correction of coagulopathy on a case-by-case basis remains the recommended approach.