Tranexamic Acid for Gastrointestinal Bleeding
Tranexamic acid (TXA) should not be used for the treatment of gastrointestinal bleeding due to lack of benefit and increased risk of thromboembolic events. 1, 2
Evidence Against TXA Use in GI Bleeding
- High-dose intravenous tranexamic acid shows no benefit in reducing mortality or rebleeding in gastrointestinal bleeding, based on high-certainty evidence from the HALT-IT trial 1, 2
- The HALT-IT trial, a large international randomized controlled trial with 12,009 patients, found no reduction in death due to bleeding within 5 days (RR 0.99,95% CI 0.82-1.18) 2
- TXA significantly increased the risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism) compared to placebo (RR 1.85,95% CI 1.15-2.98) 2
- The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials only 3
- The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1
Management Recommendations for GI Bleeding
- Standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized for all GI bleeding 1
- For upper GI bleeding, proton pump inhibitors and prompt endoscopic intervention remain the cornerstone of treatment 3
- For variceal bleeding, standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used instead of TXA 1
- All hospitals should have a GI bleeding lead and agreed pathways for the management of acute lower GI bleeding 3
- Hospitals that routinely admit patients with lower GI bleeding should have access to 7-day on-site colonoscopy and facilities to provide endoscopic therapy 3
Special Considerations
- While TXA has proven benefits in trauma and surgical bleeding (with a loading dose of 1g over 10 minutes followed by 1g over 8 hours when given within 3 hours of injury), this benefit does not translate to GI bleeding 3, 1
- Some older, smaller studies suggested potential benefits of TXA in GI bleeding 4, 5, but these have been superseded by the high-quality HALT-IT trial 2
- Low-dose or enteral TXA administration has been studied with some promising results 1, 6, but current evidence is insufficient to recommend this approach outside of clinical trials
Potential Pitfalls
- Do not extrapolate the benefits of TXA seen in trauma and surgical bleeding to GI bleeding scenarios, as the pathophysiology differs significantly 1
- Avoid using TXA in patients with liver cirrhosis and variceal bleeding due to increased risk of thrombotic complications 1
- For patients on direct oral anticoagulants (DOACs) with GI bleeding, focus on withholding the anticoagulant and considering reversal agents rather than adding TXA 3
- Be aware that TXA administration more than 3 hours after injury in trauma settings is associated with increased mortality, suggesting timing is critical when TXA is indicated 3
In conclusion, current high-quality evidence does not support the use of tranexamic acid for GI bleeding management, and its use may increase thromboembolic risk.