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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding as high-quality evidence shows no improvement in mortality or bleeding outcomes while demonstrating increased risk of thrombotic events. 1

Evidence on TXA Effectiveness in GI Bleeding

High-Dose IV TXA (≥4g/24h)

• High-dose IV TXA shows no significant benefit in reducing mortality (RR 0.98,95% CI 0.88-1.09) in GI bleeding 1, 2
• No significant reduction in rebleeding rates has been demonstrated (RR 0.92,95% CI 0.82-1.04) 1, 2
• The HALT-IT trial, a large international randomized controlled trial, conclusively showed that high-dose 24-hour TXA infusion did not reduce death due to bleeding in patients with GI hemorrhage 3
• Increased risk of adverse events is associated with high-dose IV TXA, including:
  • Deep vein thrombosis (RR 2.10,95% CI 1.08-3.72) 1, 2
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 2
  • Seizures (RR 1.73,95% CI 1.03-2.93) 2

Low-Dose IV/Enteral TXA

• Some evidence suggests low-dose IV/enteral TXA may potentially reduce rebleeding (RR 0.5,95% CI 0.38-0.88) 1, 2
• However, this evidence is of moderate certainty and requires further validation before clinical implementation 2

Current Guideline Recommendations

• The American College of Critical Care Medicine explicitly recommends against routine use of high-dose IV TXA in GI bleeding 1
• The British Society of Gastroenterology suggests confining TXA use in acute lower GI bleeding to clinical trials only 1
• Current standard of care focuses on:
  • Endoscopic therapy for direct bleeding control 1
  • Acid suppression for upper GI bleeding 1
  • Portal pressure-lowering measures for variceal bleeding 1

Special Patient Populations

• In cirrhotic patients with suspected variceal bleeding, TXA has shown no beneficial effect on mortality 1
• Caution is particularly warranted in cirrhotic patients, as:
  • Administration of blood products may paradoxically increase portal pressure 1
  • Risk of thrombotic events may be especially concerning 1

Common Pitfalls in Management

• Relying on older, smaller studies that suggested mortality benefits with TXA - these findings have been contradicted by more recent, larger, and higher-quality trials 1, 3
• Failing to recognize the increased thrombotic risk associated with TXA administration 1, 2, 3
• Using TXA as a substitute for definitive endoscopic therapy, which remains the standard of care for controlling GI bleeding 1

Clinical Decision Algorithm

1. For patients with GI bleeding, prioritize standard treatments:

   • Early endoscopic intervention 1
   • Appropriate resuscitation and hemodynamic support 1
   • Acid suppression for upper GI bleeding 1
   • Portal pressure reduction for variceal bleeding 1

2. Do NOT administer high-dose IV TXA as:

   • No mortality benefit has been demonstrated 1, 3
   • No significant reduction in rebleeding has been shown 1, 2
   • Risk of thrombotic events is increased 1, 2, 3

3. Consider low-dose TXA only in the context of clinical trials, as current evidence is insufficient to support routine use outside research settings 1, 2