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 IV TXA

• High-dose IV TXA (≥4g/24h) is not effective for GI bleeding and carries significant risks:
  • 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
  • No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• Increased adverse events 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

Special Considerations for Variceal Bleeding

• TXA is specifically contraindicated in variceal bleeding 2
• For patients with cirrhosis and variceal bleeding, TXA should not be used (Level of Evidence 2, strong recommendation) 1, 4
• In cirrhotic patients, TXA showed no beneficial effect on mortality and an almost 2-fold increase in venous thromboembolic events 1, 4

Conflicting Evidence on Low-Dose TXA

• Some smaller studies suggest potential benefits of low-dose IV/enteral TXA:
  • Possible reduction in rebleeding (RR 0.5,95% CI 0.38-0.88) 1, 5
  • Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1, 5
  • Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09) 1, 5
• 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 may reduce continued bleeding, urgent endoscopic intervention, and mortality 6, but this conflicts with the larger, more recent HALT-IT trial findings 3

Recommended Management for GI Bleeding

For Upper GI Bleeding

• Prompt resuscitation 1
• Early endoscopy for diagnosis and treatment 1, 4
• For non-variceal bleeding:
  • High-dose proton pump inhibitors (80 mg stat followed by 8 mg hourly for 72 hours) after successful endoscopic therapy 4
  • Endoscopic therapy as primary intervention 4

For Variceal Bleeding

• Vasoactive therapy (terlipressin, somatostatin, octreotide) before endoscopy 1, 4
• Prophylactic antibiotics 4
• Endoscopic band ligation 4
• Restrictive red blood cell transfusion strategy 4

Pitfalls and Caveats

• The increased risk of thrombotic events with TXA is particularly concerning 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 TXA use in acute GI bleeding should be confined to clinical trials 1, 4