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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) should not be used 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 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) 3, 2
  • No reduction in rebleeding (RR 0.92,95% CI 0.82-1.04) 3, 2
  • No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• High-dose IV TXA significantly increases adverse events:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 2, 4
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.00) 2, 4
  • Seizures (RR 1.73,95% CI 1.03-2.93) 2, 4

Low-Dose TXA

• The ESICM makes no recommendation regarding low-dose IV or enteral TXA due to limited evidence 2
• Some smaller studies suggest potential benefits of low-dose IV/enteral TXA, but these findings are not robust enough to override the high-quality evidence from the HALT-IT trial 4

Special Considerations for Variceal Bleeding

• For patients with cirrhosis and variceal bleeding, TXA is specifically contraindicated 1, 5
• The European Association for the Study of the Liver (EASL) strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 5
• In cirrhotic patients with suspected variceal bleeding:
  • TXA showed no beneficial effect on mortality 1
  • TXA showed an almost 2-fold increase in venous thromboembolic events 5

Recommended Approaches for GI Bleeding

For Upper GI Bleeding

• Prompt resuscitation and early endoscopy for diagnosis and treatment 1
• For variceal bleeding:
  • Vasoactive therapy (terlipressin, somatostatin, or octreotide) before endoscopy 5
  • Prophylactic antibiotics 5
  • Endoscopic band ligation (EBL) 5
  • Restrictive red blood cell transfusion strategy 5

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 5
• Endoscopic therapy as the primary intervention 5
• Restrictive transfusion strategy 5

Important Pitfalls and Caveats

• The increased risk of thrombotic events with TXA is particularly concerning in patients with liver disease 1, 5, 2
• While TXA has shown benefit in trauma when given early, this benefit does not extend to GI bleeding 1
• Administration of blood products can increase portal pressure, potentially worsening bleeding outcomes in cirrhotic patients 1, 2
• Dosing protocols for trauma should not be extrapolated to GI bleeding due to different pathophysiology 1
• Some older, smaller studies suggested benefits of TXA 6, 7, but these have been superseded by the large, high-quality HALT-IT trial 3

Conflicting Evidence

While some meta-analyses of smaller trials suggested potential benefits of TXA in reducing mortality and rebleeding in GI bleeding 6, 7, the large HALT-IT trial (n=12,009) found no benefit and increased harm 3. Current guidelines from multiple societies (ESICM, EASL, BSG) recommend against routine use of TXA in GI bleeding, particularly in variceal bleeding 1, 5, 2.