Tranexamic Acid (Trenexa) is Not Recommended for Acute Gastrointestinal Bleeding
Tranexamic acid is not recommended for routine use in acute gastrointestinal bleeding as it shows no reduction in mortality or rebleeding rates and may increase the risk of venous thromboembolic events, particularly in patients with cirrhosis. 1, 2
Evidence Against Tranexamic Acid in GI Bleeding
The HALT-IT trial, a large multicenter randomized controlled trial including 12,009 patients with acute GI bleeding, found that high-dose tranexamic acid did not reduce death due to bleeding within 5 days compared to placebo (3.7% vs. 3.8%, risk ratio 0.99) 2
Tranexamic acid was associated with an increased risk of venous thromboembolic events (deep vein thrombosis or pulmonary embolism) compared to placebo (0.8% vs. 0.4%, risk ratio 1.85) 2
The British Society of Gastroenterology explicitly recommends that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials 3
The American Association for the Study of Liver Diseases (AASLD) notes that tranexamic acid showed no reduction in death or bleeding in acute gastrointestinal bleeding, with a subgroup analysis showing higher risk of venous thromboembolic events in patients with cirrhosis 3
The European Association for the Study of the Liver (EASL) strongly recommends against using tranexamic acid in patients with cirrhosis and active variceal bleeding 3, 1
Specific Patient Populations and Risks
In patients with cirrhosis, the risk of venous thromboembolic events is particularly concerning, as demonstrated in subgroup analyses of the HALT-IT trial 3
The increased risk of thrombotic events may be related to the high doses of tranexamic acid used in trials but could also be related to the relative hypofibrinolysis observed in acute-on-chronic liver failure 3
Seizures occurred more frequently in patients receiving tranexamic acid compared to placebo (0.6% vs. 0.4%, risk ratio 1.73) 2
Conflicting Evidence
Some smaller meta-analyses of older, smaller trials have suggested potential benefits of tranexamic acid in reducing continued bleeding (RR = 0.60), urgent endoscopic intervention (RR = 0.35), and mortality (RR = 0.60) 4
A small randomized controlled trial (n=410) suggested that tranexamic acid may help change an urgent endoscopy to an elective procedure 5
However, these findings are contradicted by the more recent, larger, and methodologically robust HALT-IT trial 2
A recent small RCT (n=81) specifically examining lower GI bleeding found no significant effect of intravenous tranexamic acid on blood transfusion requirements 6
Recommended Management Approach for Acute GI Bleeding
Standard management with resuscitation, early endoscopic intervention, and pharmacological treatments should be prioritized over tranexamic acid 1
All hospitals should have a GI bleeding lead and agreed pathways for the management of acute GI bleeding 3, 1
For patients on anticoagulants with GI bleeding, consider interrupting direct oral anticoagulant therapy at presentation and using specific reversal agents (idarucizumab, andexanet) for life-threatening hemorrhage 3
In patients with cirrhosis and active bleeding related to portal hypertension, bleeding should be managed with portal hypertension-lowering measures rather than hemostatic agents 3
Conclusion
Based on the most recent and highest quality evidence, tranexamic acid should not be routinely used in the management of acute gastrointestinal bleeding due to lack of efficacy and potential increased risk of thromboembolic events.