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

Tranexamic Acid for Gastrointestinal Bleeding

Tranexamic acid (TXA) is not recommended for stopping gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events. 1, 2

Efficacy Evidence

• 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 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 explicitly suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials, pending results of larger studies 1

Safety Concerns

• 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) 1, 3
  • Pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1, 3
  • Seizures (RR 1.73,95% CI 1.03-2.93) 3

Special Populations

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

Conflicting Evidence

While current guidelines strongly recommend against high-dose IV TXA, there is some conflicting evidence:

• Some older, smaller studies suggested potential benefits of TXA in GI bleeding 4, 5
• Low-dose IV or enteral TXA shows potential benefits in some studies, including reduction in rebleeding (RR 0.5,95% CI 0.33-0.75) and decreased need for surgical intervention (RR 0.58,95% CI 0.38-0.88), but with only moderate certainty evidence 2, 3
• Case reports suggest possible benefit in specific scenarios such as patients who refuse blood products 6

Recommended Approach for GI Bleeding

Instead of TXA, standard management should be prioritized:

• Early resuscitation and hemodynamic stabilization 1, 2
• Prompt endoscopic intervention for diagnosis and treatment 1
• For patients on anticoagulants with GI bleeding:
  • Interrupt direct oral anticoagulant therapy at presentation 1
  • Consider specific reversal agents (idarucizumab, andexanet) for life-threatening hemorrhage on DOACs 1

Important Caveats

• Benefits seen with TXA in trauma and surgical bleeding do not translate to gastrointestinal bleeding, highlighting the importance of disease-specific evidence 2
• All hospitals should have a GI bleeding lead and agreed pathways for management of acute GI bleeding 1
• The HALT-IT trial, which provides the highest quality evidence against TXA use in GI bleeding, specifically evaluated extended-use (24 hr) high-dose TXA 7, 3