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

Tranexamic Acid for GI Bleeding: Evidence-Based Recommendations

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding as high-dose IV TXA does not improve mortality or bleeding outcomes and increases adverse events. 1

Current Evidence on TXA in GI Bleeding

High-Dose IV TXA (≥4g/24h)

• Not recommended for GI bleeding based on high-certainty evidence 1
• Shows no significant benefit in:
  • Mortality (RR 0.98,95% CI 0.88-1.09) 1
  • Rebleeding rates (RR 0.92,95% CI 0.82-1.04) 1
  • Need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• Associated with increased risk of:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1
  • Seizures (RR 1.73,95% CI 1.03-2.93) 1

Low-Dose IV/Enteral TXA

• No formal recommendation due to limited evidence (moderate certainty) 1
• May potentially reduce:
  • Rebleeding (RR 0.5,95% CI 0.38-0.88) 1
  • Need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 1
  • Possibly mortality (RR 0.62,95% CI 0.36-1.09) - though results are imprecise 1
• Safety data on thrombotic events are lacking in most trials of low-dose TXA 1

Special Considerations

Portal Hypertensive Bleeding

• In cirrhotic patients with suspected variceal bleeding, TXA has shown:
  • No beneficial effect on mortality 1
  • Increased risk of venous thromboembolic events 1
  • Potential for harm due to hypofibrinolytic state often present in critically ill cirrhotic patients 1

Upper vs. Lower GI Bleeding

• Most evidence comes from studies on upper GI bleeding 1
• Effects on lower GI bleeding remain unclear and warrant further investigation 2
• British Society of Gastroenterology guidelines (2019) suggest confining TXA use in acute lower GI bleeding to clinical trials 1

Clinical Decision Making

When to Consider TXA

• Not for routine use in GI bleeding 1
• Current guidelines recommend against high-dose IV TXA in GI bleeding 1
• The HALT-IT trial (largest RCT to date with 12,009 patients) found no mortality benefit but increased thrombotic events 3

Alternative Management Approaches

• Focus on established treatments:
  • Endoscopic therapy for bleeding control 1
  • Acid suppression for upper GI bleeding 1
  • Portal pressure-lowering measures for variceal bleeding 1

Common Pitfalls and Caveats

• Older meta-analyses suggested benefit from TXA in GI bleeding, but these results were not confirmed in larger, more recent trials 4, 3
• The HALT-IT trial (2020) provides the most definitive evidence against high-dose TXA use 3
• Potential for harm through thrombotic events must be considered, especially in patients with cirrhosis 1
• Administration of blood products in cirrhotic patients may paradoxically increase portal pressure and worsen bleeding outcomes 1

In summary, current high-quality evidence does not support the routine use of TXA for GI bleeding. While some smaller studies suggest potential benefit with low-dose or enteral TXA, more research is needed before this approach can be recommended.