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

From the Guidelines

Tranexamic acid (TXA) should not be used to stop a gastrointestinal (GI) bleed, as the most recent and highest quality evidence suggests it has no beneficial effect in variceal bleeding and may even increase the risk of venous thromboembolic events. The use of TXA in GI bleeding is still a topic of debate, but the latest guidelines and studies indicate that its benefits are limited and may be outweighed by the risks. For example, a large randomized placebo-controlled trial including 12,009 patients with acute upper gastrointestinal bleeding found no beneficial effect of TXA in reducing mortality due to bleeding, and even observed an increased incidence of venous thromboembolic events in the TXA group 1.

Some key points to consider when evaluating the use of TXA in GI bleeding include:

• The mechanism of action of TXA, which involves inhibiting fibrinolysis to stabilize blood clots, may not be effective in variceal bleeding where the role of haemostasis is limited 1.
• The risk of thrombotic complications, such as venous thromboembolic events, may be increased with the use of TXA, particularly in patients with comorbid liver disease or suspected variceal bleeding 1.
• The latest guidelines recommend against the routine use of TXA in patients with cirrhosis and active variceal bleeding, and suggest that its use should be considered on a case-by-case basis only 1.

In terms of alternative treatments, the focus should be on definitive therapies such as endoscopy or surgery for actively bleeding lesions, alongside adjunctive treatments like proton pump inhibitors, vasopressors, or blood transfusions as needed. The use of viscoelastic tests, such as thromboelastography (TEG), may also be helpful in guiding transfusion strategies and reducing blood product use in patients with cirrhosis and active upper gastrointestinal bleeds 1.

Overall, while TXA may have a role in certain types of bleeding, its use in GI bleeding is not supported by the latest evidence, and alternative treatments should be prioritized to optimize patient outcomes.

From the Research

Efficacy of Tranexamic Acid in Gastrointestinal Bleeding

• Tranexamic acid (TXA) has been studied as a potential treatment for gastrointestinal (GI) bleeding, with mixed results 2, 3, 4, 5, 6.
• A 2018 study found that TXA reduced the need for urgent endoscopy in patients with acute GI bleeding, but did not significantly affect mortality, re-bleeding, or blood transfusion rates 2.
• A 2021 systematic review and meta-analysis found that TXA significantly reduced the rates of continued bleeding, urgent endoscopic intervention, and mortality in patients with upper GI bleeding 3.
• Another 2021 study found no significant positive effect of TXA in patients with upper GI bleeding, and suggested that TXA treatment may not be effective in this population 5.
• A 2022 systematic review and meta-analysis found that extended-use high-dose IV TXA did not reduce mortality or bleeding outcomes, but low-dose IV/enteral TXA may be effective in reducing hemorrhage 4.
• A 2025 comprehensive systematic review and meta-analysis found that TXA significantly reduced rebleeding rates, particularly in upper GI bleeding, and was associated with a mortality reduction in certain sub-groups 6.

Safety and Adverse Events

• The use of TXA in GI bleeding has been associated with an increased risk of thromboembolic events, such as deep venous thrombosis and pulmonary embolism 4.
• A 2022 study found that extended-use high-dose IV TXA resulted in a small increase in deep venous thrombosis, pulmonary embolism, and seizure 4.
• However, a 2025 meta-analysis found no definitive evidence that TXA use is associated with thromboembolic events 6.

Clinical Implications

• The evidence suggests that TXA may be effective in reducing rebleeding and mortality in certain sub-groups of patients with GI bleeding, particularly those with upper GI bleeding 3, 6.
• However, the use of TXA in GI bleeding should be approached with caution, given the potential risks of thromboembolic events and other adverse effects 4.
• Further research is needed to fully understand the efficacy and safety of TXA in GI bleeding, and to determine the optimal dosing and administration regimens 3, 4, 6.