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

Tranexamic Acid (TXA) for Gastrointestinal Bleeding

High-dose intravenous tranexamic acid should not be used for gastrointestinal bleeding as it shows no benefit in reducing mortality or rebleeding while increasing the risk of thromboembolic events. 1

Efficacy of TXA in GI Bleeding

High-Dose IV TXA

• High-dose IV TXA (≥4g/24h) shows no benefit in gastrointestinal bleeding based on high-certainty evidence from multiple studies including the large HALT-IT trial 1
• No significant difference was found 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

Low-Dose IV/Enteral TXA

• Evidence for low-dose IV or enteral TXA is of moderate certainty and shows potential benefits 1, 2:
  • Reduction in rebleeding (RR 0.5,95% CI 0.33-0.75) 2
  • Decreased need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 2
  • Possible reduction in mortality (RR 0.62,95% CI 0.36-1.09), though this is limited by imprecision 1
• However, current guidelines make no recommendation regarding low-dose/enteral TXA due to limited data on safety 1

Safety Concerns

• High-dose IV TXA is associated with increased risk of adverse events 1, 2:
  • 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
• The risk of venous thromboembolic events appears particularly concentrated in patients with comorbid liver disease/suspected variceal bleeding 1

Special Considerations for Specific Types of GI Bleeding

Variceal Bleeding

• TXA should not be used in patients with cirrhosis and active variceal bleeding (strong recommendation) 1
• No beneficial effect of TXA was observed in patients with suspected variceal bleeding and liver disease comorbidity 1
• Possible reasons for ineffectiveness in variceal bleeding include:
  • Limited role of haemostasis in variceal bleeding 1
  • Frequent occurrence of hypofibrinolytic state in critically ill patients with cirrhosis 1

Portal Hypertensive Bleeding

• For bleeding related to portal hypertension but not varices (e.g., portal hypertensive gastropathy), portal hypertension-lowering measures should be the primary management approach 1
• Correction of haemostasis should be considered on a case-by-case basis if portal hypertension-lowering drugs fail 1

Non-Variceal Upper GI Bleeding

• Older studies suggested potential benefits of TXA in upper GI bleeding 3, 4, but these trials had methodological limitations and were conducted before modern endoscopic therapy and proton pump inhibitors became standard 1
• Current evidence does not support routine use of TXA for non-variceal upper GI bleeding 1

Lower GI Bleeding

• Evidence specifically for lower GI bleeding is limited 5
• The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials 1

Clinical Approach

1. For all GI bleeding:

   • Standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized 1
   • High-dose IV TXA should not be used due to lack of benefit and increased thrombotic risk 1

2. For variceal bleeding:

   • TXA should be avoided due to lack of benefit and increased thrombotic risk 1
   • Standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used 1

3. For refractory non-variceal bleeding:

   • Current evidence does not support routine use of TXA 1
   • Further research is needed on the potential role of low-dose IV or enteral TXA as rescue therapy 1

Research Gaps

• More evidence is needed on:
  • The role of low-dose IV and enteral TXA in GI bleeding 1
  • Identifying specific patient subgroups that might benefit from TXA 1
  • The potential role of TXA as rescue therapy in refractory hemorrhage 1
  • Effects of TXA specifically in lower GI bleeding 5