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

Tranexamic Acid for GI Bleeding: Current Evidence and Recommendations

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding as high-dose IV TXA does not reduce mortality or rebleeding but increases thrombotic complications. 1

Evidence on High-Dose IV TXA

High-dose intravenous TXA (4g/24h or greater) has been extensively studied for GI bleeding with the following findings:

• No reduction in mortality (RR 0.98,95% CI 0.88-1.09; high certainty evidence) 1
• No reduction in rebleeding rates (RR 0.92,95% CI 0.82-1.04; high certainty evidence) 1
• No reduction in need for surgical intervention (RR 0.91,95% CI 0.76-1.09; high certainty evidence) 1
• Increased risk of adverse events:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72; high certainty) 1, 2
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0; high certainty) 1, 2
  • Seizures (RR 1.73,95% CI 1.03-2.93; high certainty) 1

The HALT-IT trial, the largest randomized controlled trial on this topic, conclusively demonstrated that high-dose IV TXA did not reduce death from gastrointestinal bleeding but increased thrombotic complications 2.

Evidence on Low-Dose/Enteral TXA

For low-dose IV or enteral TXA, the evidence suggests:

• Possible reduction in rebleeding (RR 0.5,95% CI 0.38-0.88; moderate certainty) 1
• Possible reduction in need for surgical intervention (RR 0.58,95% CI 0.38-0.88; moderate certainty) 1
• Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09; moderate certainty) 1

However, these results are limited by imprecision and smaller trial sizes 1. Additionally, data on potential harms (DVT, PE, seizure) were not adequately reported in most of these trials 1.

Special Considerations for Different Types of GI Bleeding

Variceal Bleeding

• TXA has shown no beneficial effect in variceal bleeding 1
• A subgroup analysis of patients with suspected variceal bleeding and liver disease showed increased risk of venous thromboembolic events with TXA 1
• The limited role of TXA in variceal bleeding may be due to the limited role of haemostasis in this condition and the frequent occurrence of hypofibrinolytic states in critically ill patients with cirrhosis 1

Lower GI Bleeding

• The British Society of Gastroenterology suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 1

Current Guideline Recommendations

The European Society of Intensive Care Medicine makes the following recommendations 1:

1. High-dose IV TXA: Not recommended for critically ill patients with gastrointestinal bleeding (Conditional recommendation, high certainty evidence)
2. Low-dose IV/enteral TXA: No recommendation due to insufficient evidence (No recommendation, moderate certainty evidence)

Clinical Algorithm for TXA Use in GI Bleeding

1. For acute GI bleeding in general:

   • Do not use high-dose IV TXA (4g/24h or greater) 1
   • Focus on established treatments: endoscopic therapy, acid suppression, and correction of coagulopathy if indicated 1

2. For patients with variceal bleeding:

   • Avoid TXA due to increased risk of thrombotic events 1
   • Use standard therapy including vasoactive drugs, antibiotics, and endoscopic band ligation 1

3. For refractory non-variceal bleeding:

   • Consider other interventions such as repeat endoscopic therapy or interventional radiology 1
   • Low-dose/enteral TXA might be considered in selected cases with severe bleeding not responding to standard therapy, but evidence is limited 1

Common Pitfalls and Caveats

• Despite TXA's effectiveness in trauma and surgical bleeding, this benefit does not extend to GI bleeding 1, 2
• Historical meta-analyses suggesting benefit from TXA in GI bleeding were based on small, low-quality trials conducted before modern endoscopic therapy 1, 3
• The absolute increase in thrombotic events with high-dose TXA is small but clinically significant 1, 2
• The potential benefit of low-dose/enteral TXA requires further research before clinical implementation 1
• Patients with liver disease may be at particularly high risk of thrombotic complications from TXA 1

In summary, current high-quality evidence does not support the routine use of TXA for GI bleeding, and it may increase harm through thrombotic complications. Standard endoscopic and pharmacological approaches remain the mainstay of treatment.