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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for the treatment of gastrointestinal bleeding as it does not reduce mortality or rebleeding and increases the risk of thromboembolic events. 1, 2, 3

Evidence Against TXA Use in GI Bleeding

• High-dose intravenous TXA (≥4g/24h) has been shown to:

  • Not reduce mortality (RR 0.98,95% CI 0.88-1.09) 1, 2
  • Not reduce rebleeding (RR 0.92,95% CI 0.82-1.04) 1, 2
  • Not reduce need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
  • Increase risk of deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1, 2
  • Increase risk of pulmonary embolism (RR 1.78,95% CI 1.06-3.00) 1, 2
  • Increase risk of seizures (RR 1.73,95% CI 1.03-2.93) 1, 2

• The HALT-IT trial, the largest and most recent randomized controlled trial (12,009 patients), conclusively demonstrated that TXA does not reduce death from GI bleeding but increases thromboembolic events 3

Special Considerations for Variceal Bleeding

• For patients with cirrhosis and variceal bleeding, TXA is specifically contraindicated (Level of Evidence 2, strong recommendation) 1, 2
• In cirrhotic patients with suspected variceal bleeding, TXA showed:
  • No beneficial effect on mortality 1
  • An almost 2-fold increase in venous thromboembolic events 1, 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

Conflicting Evidence on Low-Dose TXA

• Some smaller studies suggest potential benefits of low-dose IV or enteral TXA, including:

  • 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, 2
  • Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09) 1, 2

• However, the European Society of Intensive Care Medicine (ESICM) makes no recommendation regarding low-dose IV or enteral TXA due to limited evidence 2

• A 2021 meta-analysis suggested TXA might be effective for upper GI bleeding, but this is contradicted by the larger, more recent guidelines and the HALT-IT trial 5, 3

Recommended First-Line Treatments for GI Bleeding

For Variceal Bleeding:

• Prompt initiation of vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 4
• Prophylactic antibiotics 4
• Endoscopic band ligation (EBL) 4
• Restrictive red blood cell transfusion strategy 4

For Non-Variceal Upper GI Bleeding:

• High-dose proton pump inhibitors (80 mg stat followed by an infusion of 8 mg hourly for 72 hours) following successful endoscopic therapy 4
• Endoscopic therapy as the primary intervention 4
• Restrictive transfusion strategy 4

Pitfalls and Caveats

• The increased risk of thrombotic complications with TXA appears to be particularly elevated in patients with liver disease 1, 4, 2
• TXA has shown benefit in trauma when given early, but 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
• The British Society of Gastroenterology suggests that the use of TXA in acute GI bleeding should be confined to clinical trials 1, 4