Tranexamic Acid for Gastrointestinal Bleeding
Tranexamic acid (TXA) should not be used for gastrointestinal bleeding as it shows no benefit in reducing mortality or rebleeding while increasing the risk of thromboembolic events. 1, 2
Efficacy Evidence
- High-dose intravenous TXA shows no 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 from the HALT-IT trial 2
- The HALT-IT trial, a large international randomized controlled trial with 12,009 patients, conclusively demonstrated that TXA did not reduce death from gastrointestinal bleeding compared to placebo 3
- Local administration of TXA also confers no additional benefit over standard care in patients with upper gastrointestinal hemorrhage 4
Safety Concerns
- TXA increases the risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism) compared to placebo (RR 1.85; 95% CI 1.15 to 2.98) 3
- The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding, based on high-certainty evidence 1, 2
- TXA administration more than 3 hours after injury in trauma settings is associated with increased mortality, suggesting timing is critical when TXA is indicated in other conditions 1
Current Guideline Recommendations
- The American College of Gastroenterology does not recommend high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 2
- The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials only 1, 2
- For upper GI bleeding, proton pump inhibitors and prompt endoscopic intervention remain the cornerstone of treatment 1
Important Clinical Considerations
- While TXA has proven benefits in trauma, surgical bleeding, and postpartum hemorrhage, this benefit does not translate to GI bleeding 1, 2
- For variceal bleeding, standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used instead of TXA 1, 2
- For patients on direct oral anticoagulants (DOACs) with GI bleeding, focus on withholding the anticoagulant and considering reversal agents rather than adding TXA 1
Common Pitfalls
- Older, smaller meta-analyses suggested potential benefits of TXA in GI bleeding 5, 6, but these have been superseded by the high-quality HALT-IT trial which showed no benefit 3
- Clinicians might be tempted to extrapolate TXA's benefits from trauma and surgical bleeding to GI bleeding, but disease-specific evidence clearly shows this extrapolation is not valid 2
- Some clinicians might consider low-dose TXA regimens, but current evidence does not support this approach outside of clinical trials 2