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

TXA for GI Bleeding: Recommendation and Practical Approach

No—do not use tranexamic acid (TXA) to stop a GI bleed, because it does not improve mortality or rebleeding and increases thromboembolic harms; prioritize standard resuscitation, endoscopic therapy, and guideline-directed pharmacologic care instead. 1, 2

Why TXA should not be used (Morbidity, Mortality, QOL)

• The highest-quality, most recent evidence shows high-dose IV TXA does not reduce mortality or rebleeding, but increases DVT, PE, and seizures (high-certainty): RR mortality 0.98, DVT 2.01, PE 1.78, seizures 1.73 2.
• Major GI societies advise against high-dose IV TXA for GI bleeding due to lack of benefit and increased thrombotic risk, based on HALT-IT–level evidence (endorsed by ACG and BSG) 1.
• For cirrhosis with active variceal bleeding, the European Association for the Study of the Liver recommends against TXA (strong recommendation), due to unfavorable risk–benefit and alternative effective therapies 3, 1.
• BSG advises TXA use for acute lower GI bleeding only within clinical trials (do not use routinely) 3, 1.

Nuance:

• Low-dose IV or enteral TXA has signal for reduced rebleeding and surgery in older/smaller trials, but no mortality benefit and uncertain safety; not recommended for routine care or to “stop” bleeding in practice 1, 2.
• Older meta-analyses suggesting benefit are outweighed by larger, methodologically stronger, contemporary evidence showing no benefit and increased harm (HALT-IT era) 2.

What to do instead (Algorithm for Acute GI Bleeding)

1. Immediate priorities (do these first, not TXA)

• Aggressive resuscitation, hemodynamic stabilization, and activation of institutional GI bleed pathways; coordinate early with endoscopy and interventional radiology/surgery as needed 3.
• Early endoscopy for diagnosis and definitive hemostasis is recommended for acute GI bleeding (upper or lower) 3.
• Pharmacologic therapy per bleeding phenotype: for suspected/known variceal bleeding, use vasoactive agents (e.g., octreotide/terlipressin), antibiotics, and endoscopic band ligation; TXA should be avoided 1.

1. Anticoagulation management (when applicable)

• Interrupt DOACs at presentation for GI bleeding; for life-threatening hemorrhage, consider specific reversal agents (idarucizumab for dabigatran; andexanet alfa for apixaban/rivaroxaban) to improve hemostasis and outcomes 3.

1. What to avoid

• Do not give high-dose IV TXA (e.g., HALT-IT regimen: 1 g bolus + 3 g over 24 h), as it fails to improve mortality/rebleeding and increases DVT/PE/seizures 4, 2.
• Avoid TXA entirely in cirrhosis with variceal bleeding (strong recommendation against by EASL) 3, 1.
• For acute lower GI bleeding, do not use TXA outside a research protocol (BSG) 3, 1.

Special Situations and Caveats

• Do not extrapolate from trauma/postpartum/surgical TXA benefits to GI bleeding—disease-specific evidence shows no net benefit and higher thrombotic risk in GI bleeding 1, 2.
• Case reports of TXA “success” (e.g., Jehovah’s Witness patients) are anecdotal and do not outweigh RCT/meta-analysis evidence or guideline recommendations; avoid TXA outside trials even in difficult scenarios 5, 1, 2.
• The harms signal (DVT/PE/seizure) is clinically meaningful and threatens morbidity, mortality, and quality of life; do not delay definitive endoscopic or radiologic therapy by attempting TXA 2, 3.

Bottom line

• Use standard, guideline-directed GI bleed care (resuscitation, early endoscopy, appropriate pharmacotherapy, and anticoagulant reversal when indicated). Do not use TXA to stop GI bleeding outside clinical trials; avoid entirely in cirrhosis with variceal bleeding 3, 1.