Recommendation
- No — do not use tranexamic acid (TXA) to stop a GI bleed, because it does not improve survival or rebleeding and increases thromboembolic harm. 1
Why TXA should not be used for GI bleeding (morbidity, mortality, QOL)
- High-dose IV TXA does not reduce mortality or rebleeding and increases DVT, PE, and seizures (high-certainty evidence) 1.
- Contemporary guideline positions reflect this evidence: professional societies advise against high-dose IV TXA and against any TXA use in variceal bleeding, prioritizing standard therapies instead 2, 3, 4.
What to do instead (simple algorithm)
- Prioritize proven therapies:
- Rapid resuscitation and early endoscopic evaluation/treatment for all GI bleeding; do not delay endoscopy to give TXA 2, 3.
- Upper GI bleeding: give proton pump inhibitor and arrange prompt endoscopy; endoscopic hemostasis as indicated 4.
- Suspected/known variceal bleeding (cirrhosis): start vasoactive agent (e.g., octreotide/terlipressin), prophylactic antibiotics, and perform endoscopic band ligation; avoid TXA 4.
- On DOACs: interrupt the anticoagulant at presentation and consider specific reversal (idarucizumab for dabigatran; andexanet for factor Xa inhibitors) for life-threatening hemorrhage 3.
- Avoid TXA routinely in all GI bleeding, including as “rescue,” outside a clinical trial; this reduces thrombotic complications without sacrificing hemostasis outcomes 2, 3.
How the evidence fits together (and why earlier signals don’t change practice)
- Most recent, highest-quality meta-analysis: no mortality or rebleeding benefit with high-dose IV TXA and increased thromboembolic events; low-dose/enteral regimens show reduced rebleeding but no mortality benefit and insufficient safety data (not ready for practice) 1.
- Large-practice-changing trial data underpin these conclusions, which are adopted by guideline bodies (e.g., ACG, BSG, EASL) that recommend against TXA use in GI bleeding, especially in variceal bleeding and cirrhosis 2, 3, 4.
- Older/heterogeneous and smaller studies suggesting benefit:
- A 2021 meta-analysis reported mortality and bleeding advantages but was limited by small, heterogeneous trials and is superseded by larger, higher-quality evidence showing no benefit and harm with high-dose IV TXA 5.
- A 2018 RCT noted fewer “urgent endoscopies” with TXA but no improvement in mortality, rebleeding, transfusion, or interventions—so no meaningful patient-centered benefit 6.
- A 2024 RCT in lower GI bleeding showed no reduction in transfusion needs with TXA 7.
Special populations and caveats
- Cirrhosis/variceal hemorrhage: avoid TXA; guideline recommendation is strong against use due to lack of benefit and increased VTE risk 3.
- High-dose IV TXA (as studied in recent large trials) increases DVT/PE and seizures; this worsens morbidity and QOL without offsetting benefits 1.
- Do not extrapolate TXA benefits from trauma/obstetric/surgical settings to GI bleeding; disease-specific data do not support efficacy in GI hemorrhage 2, 4.