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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) should not be used for gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1

Efficacy Evidence

• High-dose intravenous TXA (1g loading dose followed by 3g over 24 hours) shows no benefit in reducing mortality (RR 0.98,95% CI 0.88-1.09) or rebleeding rates (RR 0.92,95% CI 0.82-1.04) in gastrointestinal bleeding based on high-certainty evidence from the HALT-IT trial 2

• Extended-use high-dose IV TXA increases the risk of thromboembolic events:

  • Deep venous thrombosis (RR 2.01,95% CI 1.08-3.72) 3
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 3
  • Overall venous thromboembolic events were higher with TXA (0.8%) compared to placebo (0.4%) (RR 1.85,95% CI 1.15-2.98) 2

• The American College of Gastroenterology does not recommend TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 1

Contrasting Evidence

• Some older, smaller studies suggested potential benefits:

  • Low-dose IV or enteral TXA showed potential reduction in rebleeding (RR 0.5,95% CI 0.33-0.75) and decreased need for surgical intervention (RR 0.58,95% CI 0.38-0.88) with moderate certainty evidence 3

• A 2021 meta-analysis suggested TXA reduced continued bleeding (RR 0.60,95% CI 0.43-0.84) and mortality (RR 0.60,95% CI 0.45-0.80) compared to placebo 4

• However, these findings have been superseded by the larger, more recent HALT-IT trial which had superior methodology and included 12,009 patients 2

Special Considerations

• The European Association for the Study of the Liver specifically recommends against using TXA in patients with cirrhosis and active variceal bleeding (strong recommendation) 1

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

• For variceal bleeding, standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used instead 1

Clinical Approach to GI Bleeding

• Standard management should be prioritized:

  • Resuscitation and hemodynamic stabilization 1
  • Early endoscopic therapy for diagnosis and treatment 1
  • Appropriate pharmacological treatments (e.g., proton pump inhibitors for upper GI bleeding) 1

• TXA should not be used routinely in the management of GI bleeding due to:

  • Lack of mortality benefit in the largest and most recent trial 2
  • Increased risk of thromboembolic events 2, 3
  • Clear recommendations against its use in current guidelines 1

• While TXA has shown benefits in trauma and surgical bleeding 5, this does not translate to GI bleeding, highlighting the importance of disease-specific evidence rather than extrapolating from other clinical scenarios 1, 2