Tranexamic Acid for Gastrointestinal Bleeding
Tranexamic acid (TXA) is not recommended for stopping gastrointestinal (GI) bleeds due to lack of mortality benefit and increased risk of thromboembolic events, based on high-certainty evidence from recent clinical trials. 1
Evidence Against TXA Use 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 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) and pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 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 1
- The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 3, 2
- The British Society of Gastroenterology explicitly suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials only 3, 2
Special Patient Populations
- For patients with cirrhosis, TXA has shown no benefit in controlling esophageal variceal hemorrhage and may increase the risk of venous thromboembolism events 4
- A recent international multicenter, randomized, double-blind, placebo-controlled trial showed the risk of VTE events to be higher in patients with cirrhosis receiving tranexamic acid 4
- For patients with bleeding disorders of unknown cause, TXA is commonly used for prophylaxis in minor procedures (72%), major procedures (59%), and deliveries (58%), but evidence quality is very low 4
Conflicting Evidence
- While high-dose IV TXA shows no benefit, some evidence suggests potential benefits of low-dose IV or enteral TXA, 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) 1
- Older, smaller studies suggested TXA might decrease rebleeding rates and need for surgery 5, but these findings have not been confirmed in larger, more recent trials
- A small pilot study in dialysis patients with upper GI bleeding suggested potential benefits of TXA in decreasing early rebleeding and need for blood transfusions, but this was a non-randomized trial with significant limitations 6
- A recent randomized controlled trial found that intravenous TXA had no significant effect on blood transfusion requirements in patients with lower GI bleeding 7
Recommended Approach for GI Bleeding
- Standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized over TXA 2
- For upper GI bleeding, proton pump inhibitors and prompt endoscopic intervention remain the cornerstone of treatment 3
- For variceal bleeding, standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used instead of TXA 3
- For patients on anticoagulants with GI bleeding, consider interrupting therapy and using specific reversal agents for life-threatening hemorrhage rather than adding TXA 2
In conclusion, current high-quality evidence does not support the use of TXA for stopping GI bleeds in routine clinical practice, and it may increase thromboembolic risk. The focus should remain on established treatments including endoscopic intervention, proton pump inhibitors for non-variceal bleeding, and vasoactive drugs plus endoscopic band ligation for variceal bleeding.