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 as it does not reduce mortality or rebleeding but increases the risk of thrombotic complications. 1

Evidence Summary and Recommendations

High-Dose IV TXA (≥4g/24h)

• The European Society of Intensive Care Medicine (ESICM) provides a conditional recommendation against using high-dose IV TXA in critically ill patients with GI bleeding 1
• Evidence from multiple studies, including the large HALT-IT trial, shows:
  • No reduction in mortality (RR 0.98,95% CI 0.88-1.09) 1, 2
  • No reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 1, 2
  • 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

• ESICM makes no recommendation regarding low-dose IV or enteral TXA due to limited evidence 1
• Some smaller studies suggest potential benefits:
  • Possible reduction in rebleeding (RR 0.5,95% CI 0.38-0.88) 1, 2
  • Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
  • Possible reduction in mortality, though not statistically significant (RR 0.62,95% CI 0.36-1.09) 1, 2

Special Considerations for Different Types of GI Bleeding

Upper GI Bleeding

• Some older, smaller studies suggested benefits of TXA in upper GI bleeding 3, 4
• However, more recent and larger trials have not confirmed these benefits 1, 2

Lower GI Bleeding

• A recent 2024 randomized controlled trial found no significant effect of TXA on blood transfusion requirements in lower GI bleeding 5
• British Society of Gastroenterology guidelines suggest that use of TXA in acute lower GI bleeding should be confined to clinical trials 1

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

Important 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 Considerations: If considering low-dose TXA (despite limited evidence), early administration would be most beneficial, similar to its use in other bleeding conditions 1

3. Alternative Treatments for Variceal Bleeding: For variceal bleeding, vasoactive drugs, antibiotics, and endoscopic band ligation are recommended instead of TXA 1

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

5. Conflicting Evidence: While some older and smaller studies suggest benefits 3, 4, the most recent and highest quality evidence does not support routine TXA use in GI bleeding 1, 5, 2