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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) should not be used for gastrointestinal bleeding as it does not reduce mortality or rebleeding rates and increases the risk of thromboembolic events. 1, 2, 3

Evidence Against High-Dose IV TXA in 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, based on high-certainty evidence 1, 2
• TXA administration is associated with increased risk of thromboembolic events, including:
  • Deep venous thrombosis (RR 2.01,95% CI 1.08-3.72) 4
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 4
  • Seizures (RR 1.73,95% CI 1.03-2.93) 4
• The American College of Gastroenterology explicitly recommends against high-dose IV TXA for GI bleeding due to lack of benefit and increased thrombotic risk 1

Specific Recommendations by GI Bleeding Type

• For upper GI bleeding:

  • Standard management with resuscitation, proton pump inhibitors, and prompt endoscopic intervention remains the cornerstone of treatment 2, 3
  • The HALT-IT trial (n=12,009) demonstrated that TXA did not reduce death from gastrointestinal bleeding compared to placebo 5

• For lower GI bleeding:

  • The British Society of Gastroenterology suggests that use of TXA should be confined to clinical trials only 2, 3
  • Standard management approaches should be prioritized over TXA 2

• For variceal bleeding:

  • The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1, 2, 3
  • Standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used instead of TXA 1, 3

Conflicting Evidence on Low-Dose/Enteral TXA

• While high-dose IV TXA is clearly not beneficial, there is moderate-certainty evidence suggesting potential benefits of low-dose IV or enteral TXA:

  • Reduction in rebleeding (RR 0.5,95% CI 0.33-0.75) 4
  • Decreased need for surgical intervention (RR 0.58,95% CI 0.38-0.88) 4
  • Some older meta-analyses suggested mortality benefits (RR 0.60,95% CI 0.45-0.80) 6

• However, current guidelines still do not recommend low-dose TXA for routine clinical use outside of trials due to:

  • Methodological limitations in older studies 7
  • Lack of inclusion of modern endoscopic techniques in most trials 7
  • Uncertain safety profile at lower doses 4

Important Clinical Considerations

• Despite TXA's proven benefits in trauma and surgical bleeding, these benefits do not translate to GI bleeding 1, 3
• For patients on anticoagulants with GI bleeding, focus on withholding the anticoagulant and considering specific reversal agents rather than adding TXA 2
• All hospitals should have a GI bleeding lead and agreed pathways for management of acute GI bleeding 2, 3