Tranexamic Acid for Gastrointestinal Bleeding
Tranexamic acid (TXA) is not recommended for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk, based on high-certainty evidence. 1
Current Evidence and Recommendations
- High-dose intravenous TXA shows no benefit in reducing mortality or rebleeding in gastrointestinal bleeding while increasing the risk of thromboembolic events 1
- The British Society of Gastroenterology suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials, pending results of further research 2
- The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1
Mechanism and Historical Context
- TXA works by inhibiting the breakdown of fibrin clots by plasmin 3
- While TXA has shown benefits in trauma and surgical bleeding, these benefits do not translate to gastrointestinal bleeding 1
- Earlier meta-analyses of older, smaller studies suggested potential benefits, but these were not confirmed in larger, more rigorous trials 4, 5
Evidence from Major Trials
- The HALT-IT trial (high-quality evidence) demonstrated:
Special Considerations
For patients with upper or lower GI bleeding, standard management should include:
For patients on anticoagulants with GI bleeding:
Research Gaps
- Evidence for low-dose IV or enteral TXA is of moderate certainty and shows potential benefits, but requires further investigation 1
- There may be specific scenarios (such as patients refusing blood products) where TXA might be considered as a rescue therapy, but this remains anecdotal 7
Clinical Bottom Line
- Standard management of GI bleeding should focus on resuscitation, endoscopic therapy, and appropriate pharmacological treatments 2
- TXA should not be routinely used for GI bleeding outside of clinical trials 2, 1
- For patients with refractory bleeding, other interventions such as interventional radiology or surgery should be considered before TXA 2