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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for gastrointestinal bleeding as it does not effectively stop GI bleeds and increases the risk of thrombotic complications. 1, 2

Evidence Against TXA Use in GI Bleeding

High-Dose IV TXA

• The European Society of Intensive Care Medicine (ESICM) provides a conditional recommendation against using high-dose IV TXA (≥4g/24h) in GI bleeding based on high-certainty evidence 1, 2
• The large HALT-IT trial demonstrated:
  • 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
• Significant increased risks with high-dose TXA:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1, 2
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.00) 1, 2
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1, 2

Low-Dose IV/Enteral TXA

• While some smaller studies suggest potential benefits of low-dose IV/enteral TXA 3, the ESICM makes no recommendation regarding this approach due to limited evidence 2
• The British Society of Gastroenterology suggests that TXA use in acute GI bleeding should be confined to clinical trials 4

Special Considerations for Specific GI Bleeding Types

Variceal Bleeding

• TXA is specifically contraindicated in variceal bleeding 2, 4
• The European Association for the Study of the Liver (EASL) strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 4
• In cirrhotic patients with suspected variceal bleeding, TXA showed:
  • No beneficial effect on mortality 4
  • Almost 2-fold increase in venous thromboembolic events 4

Reasons for TXA Ineffectiveness in GI Bleeding

• Limited role of fibrinolysis in variceal bleeding mechanisms 4
• Critically ill patients with cirrhosis often have a hypofibrinolytic state, making antifibrinolytics potentially harmful 4

Recommended Approaches for GI Bleeding Management

For Upper GI Bleeding

• Prompt resuscitation 1
• Early endoscopy for diagnosis and treatment 1
• For variceal bleeding:
  • Vasoactive drugs (terlipressin, somatostatin, octreotide) 1, 4
  • Prophylactic antibiotics 4
  • Endoscopic band ligation 4
  • Restrictive red blood cell transfusion strategy 4

For Non-Variceal Upper GI Bleeding

• High-dose proton pump inhibitors 4
• Endoscopic therapy as primary intervention 4
• Restrictive transfusion strategy 4

Pitfalls and Caveats

• The risk of thrombotic complications with TXA appears to be particularly elevated in patients with liver disease 2, 4
• Despite TXA showing benefits in trauma when given early, this benefit does not extend to GI bleeding 1
• Administration of blood products can increase portal pressure in cirrhotic patients, potentially worsening bleeding outcomes 1, 2
• Dosing protocols for trauma should not be extrapolated to GI bleeding due to different pathophysiology 1

While some older, smaller studies suggested potential benefits of TXA in GI bleeding 5, 6, 7, the most recent high-quality evidence from large randomized controlled trials does not support its use and demonstrates increased thrombotic risks.