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

Tranexamic Acid for GI Bleeding

Tranexamic acid (TXA) is not recommended for routine use in gastrointestinal bleeding as high-quality evidence shows no benefit in reducing mortality or rebleeding while increasing the risk of thromboembolic events. 1

Current Evidence on TXA for GI Bleeding

• High-dose intravenous TXA shows 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 1, 2
• The British Society of Gastroenterology explicitly suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials, pending results of larger studies 3
• High-dose IV TXA is associated with increased risk of thromboembolic events, including deep venous thrombosis (RR 2.01,95% CI 1.08-3.72) and pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1, 2
• The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1

Conflicting Evidence

• While older, smaller studies suggested potential benefits of TXA in upper GI bleeding with a possible reduction in all-cause mortality 4, these findings were not confirmed in larger, more recent trials 1
• Some evidence suggests low-dose IV or enteral TXA may reduce rebleeding (RR 0.5,95% CI 0.33-0.75) and need for surgery (RR 0.58,95% CI 0.38-0.88), but this evidence is of moderate certainty and requires further validation 2
• A 2021 meta-analysis suggested TXA might reduce continued bleeding (RR = 0.60; 95%CI, 0.43-0.84) and mortality (RR = 0.60; 95%CI, 0.45-0.80) 5, but this analysis included older studies and did not differentiate between high-dose and low-dose regimens

Clinical Approach to GI Bleeding

• Standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized over TXA 1
• For patients with acute GI bleeding:
  • Focus on hemodynamic stabilization 1
  • Perform early endoscopic intervention for diagnosis and treatment 3
  • Consider interventional radiology for cases refractory to endoscopic management 3
• For patients on anticoagulants with GI bleeding:
  • Interrupt direct oral anticoagulant therapy at presentation 3
  • Consider specific reversal agents (idarucizumab, andexanet) for life-threatening hemorrhage on DOACs 3
  • Consider restarting anticoagulation approximately 7 days after bleeding cessation 3

Special Considerations

• Case reports suggest TXA might be considered in exceptional circumstances, such as Jehovah's Witness patients who refuse blood products 6, but this remains anecdotal evidence
• The risk-benefit profile is particularly unfavorable in patients with cirrhosis and variceal bleeding, where TXA should be avoided 1
• All hospitals should have a GI bleeding lead and agreed pathways for management of acute GI bleeding 3