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 while increasing the risk of thromboembolic events. 1
Efficacy Evidence
- High-dose intravenous TXA has demonstrated no significant 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 1, 2
- The American College of Gastroenterology explicitly does not recommend high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 1
- While TXA has shown benefits in trauma and surgical bleeding, these benefits do not translate to gastrointestinal bleeding, highlighting the importance of disease-specific evidence 1
Safety Concerns
- High-dose IV TXA increases the risk of thromboembolic events, including:
- The European Association for the Study of the Liver specifically recommends against TXA use in patients with cirrhosis and active variceal bleeding (strong recommendation) 1
Special Considerations for Different GI Bleeding Types
- For variceal bleeding: Standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used, and TXA should be avoided 1
- For lower GI bleeding: The British Society of Gastroenterology suggests that TXA use should be confined to clinical trials only 1
- For all GI bleeding: Standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized 1
Conflicting Evidence
Some older and smaller studies suggested potential benefits of TXA:
- A 2021 meta-analysis reported that TXA reduced continued bleeding (RR 0.60; 95%CI, 0.43-0.84) and mortality (RR 0.60; 95%CI, 0.45-0.80) 3
- Low-dose IV or enteral TXA has shown potential benefits in reducing rebleeding (RR 0.5,95% CI 0.33-0.75) and need for surgery (RR 0.58,95% CI 0.38-0.88) with moderate certainty evidence 2
However, the most recent and highest quality evidence from the HALT-IT trial demonstrates no benefit with increased harm 1, 4
A 2020 randomized controlled trial of locally administered TXA found no statistically significant difference in composite outcomes compared to placebo (32.1% vs 29.1%, p=0.690) 5
Clinical Approach
- For acute GI bleeding management:
- Focus on standard treatments: fluid resuscitation, blood product transfusion as needed, proton pump inhibitors, and prompt endoscopic evaluation and intervention 1
- Avoid high-dose IV TXA due to lack of benefit and increased thrombotic risk 1
- Do not use TXA in patients with cirrhosis and variceal bleeding 1
- For refractory non-variceal bleeding, current evidence does not support routine use of TXA 1