Tranexamic Acid is Unsafe in GI Bleeding Due to Increased Thromboembolic Risk Without Mortality Benefit
Tranexamic acid (TXA) should not be used for gastrointestinal bleeding as it increases the risk of venous thromboembolism without improving mortality or bleeding outcomes. 1
Evidence Against TXA in GI Bleeding
The evidence against using TXA in GI bleeding is substantial and comes from high-quality research:
The HALT-IT trial, the largest and most recent randomized controlled trial on this topic, demonstrated that high-dose IV TXA (1g loading dose followed by 3g over 24 hours) did not reduce:
- Mortality (RR 0.98,95% CI 0.88-1.09)
- Rebleeding (RR 0.92,95% CI 0.82-1.04)
- Need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 2
Instead, TXA significantly increased the risk of:
- Deep vein thrombosis (RR 2.01,95% CI 1.08-3.72)
- Pulmonary embolism (RR 1.78,95% CI 1.06-3.00)
- Seizures (RR 1.73,95% CI 1.03-2.93) 3
Special Considerations in Cirrhotic Patients
The risks are even more pronounced in patients with cirrhosis and variceal bleeding:
The European Association for the Study of the Liver (EASL) guidelines explicitly discourage the routine use of TXA in patients with cirrhosis undergoing invasive procedures (LoE 4, weak recommendation) 4
In cirrhotic patients with suspected variceal bleeding, TXA showed:
- No beneficial effect on mortality
- An almost 2-fold increase in venous thromboembolic events 1
Contrast with TXA Use in Trauma
It's important to note the difference between TXA use in trauma versus GI bleeding:
In trauma patients, TXA has demonstrated mortality benefit when administered within 3 hours of injury (Grade 1A recommendation) 4
This benefit does not extend to GI bleeding, highlighting the different pathophysiological mechanisms at play 1
Current Guideline Recommendations
The British Society of Gastroenterology guidelines on acute lower GI bleeding state:
- "At this time we suggest that use of tranexamic acid in acute LGIB is confined to clinical trials, pending the results of the HALT-IT trial." 4
Now that the HALT-IT trial results are available showing no benefit and increased harm, the case against TXA in GI bleeding is even stronger.
Potential Exceptions and Alternative Approaches
While high-dose IV TXA is clearly harmful, some research suggests low-dose IV or enteral TXA might have different risk-benefit profiles:
- Low-dose/enteral TXA may potentially reduce:
- Risk of rebleeding (RR 0.5,95% CI 0.33-0.75)
- Need for surgery (RR 0.58,95% CI 0.38-0.88) 3
However, more evidence is needed regarding the safety of these alternative dosing strategies before they can be recommended.
Conclusion
Based on the most recent and highest quality evidence, TXA should not be used for GI bleeding due to increased thromboembolic risk without mortality benefit. The standard of care should focus on prompt resuscitation, early endoscopy, and specific therapies based on bleeding etiology.