Tranexamic Acid for Gastrointestinal Bleeding
Tranexamic acid (TXA) should not be used for gastrointestinal bleeding as high-dose intravenous TXA shows no benefit in reducing mortality or rebleeding and increases the risk of thromboembolic events. 1
Evidence Against TXA Use in GI Bleeding
- High-dose intravenous TXA demonstrates no significant difference in mortality (RR 0.98,95% CI 0.88-1.09), rebleeding rates (RR 0.92,95% CI 0.82-1.04), or need for surgical intervention (RR 0.91,95% CI 0.76-1.09) compared to placebo 1
- The American College of Gastroenterology does not recommend high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 1
- The HALT-IT trial, a large international randomized controlled trial, found that TXA did not reduce death from gastrointestinal bleeding but increased venous thromboembolic events (RR 1.85; 95% CI 1.15 to 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
Special Considerations for Different Types of GI Bleeding
- For variceal bleeding, TXA is specifically contraindicated - the European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1, 3
- Standard therapy for variceal bleeding should include vasoactive drugs, antibiotics, and endoscopic band ligation instead of TXA 3
- For upper GI bleeding, proton pump inhibitors and prompt endoscopic intervention remain the cornerstone of treatment 3
Low-Dose TXA Considerations
- Evidence for low-dose IV or enteral TXA is of moderate certainty and shows potential benefits, including 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) 4
- However, this evidence is not strong enough to override the recommendations against TXA use from major gastroenterology societies 1, 3
Important Clinical Pitfalls
- Despite TXA's proven benefits in trauma and surgical bleeding, these benefits do not translate to GI bleeding - highlighting the importance of disease-specific evidence rather than extrapolating from other clinical scenarios 1
- For patients on direct oral anticoagulants (DOACs) with GI bleeding, focus should be on withholding the anticoagulant and considering reversal agents rather than adding TXA 3
- All hospitals should have a GI bleeding lead and agreed pathways for the management of acute GI bleeding that do not include routine TXA administration 3
Adverse Effects of TXA in GI Bleeding
- High-dose IV TXA increases the risk of deep venous thrombosis (RR 2.01; 95% CI 1.08-3.72), pulmonary embolism (RR 1.78; 95% CI 1.06-3.0), and seizures (RR 1.73; 95% CI 1.03-2.93) 4
- The increased thromboembolic risk without mortality benefit makes TXA's risk-benefit profile unfavorable for GI bleeding 1, 2