Tranexamic Acid Should Not Be Used for Gastrointestinal Bleeding
Do not use tranexamic acid for gastrointestinal bleeding—it provides no mortality benefit and increases the risk of dangerous blood clots. 1, 2
Evidence Against TXA Use
The highest quality evidence comes from the HALT-IT trial, a large international randomized controlled trial of nearly 12,000 patients that definitively showed:
- No reduction in death from bleeding (RR 0.99,95% CI 0.82-1.18) 3
- No reduction in rebleeding rates (RR 0.92,95% CI 0.82-1.04) 1
- Increased venous thromboembolism risk, including deep vein thrombosis (RR 2.01,95% CI 1.08-3.72) and pulmonary embolism (RR 1.78,95% CI 1.06-3.0) 1, 3
Current Guideline Recommendations
Multiple major gastroenterology societies explicitly recommend against TXA:
- 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 suggests TXA use in acute lower GI bleeding should be confined to clinical trials only, pending results of larger studies 1, 2
- The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1, 2
What to Do Instead
Focus on evidence-based standard management:
- Resuscitation with restrictive transfusion strategy (target hemoglobin 7-9 g/dL in upper GI bleeding) 2
- Early endoscopic intervention for diagnosis and treatment 1
- High-dose proton pump inhibitor therapy (80 mg omeprazole stat followed by 8 mg/hour infusion for 72 hours) following successful endoscopic therapy for ulcer bleeding 4
- For variceal bleeding: vasoactive drugs, antibiotics, and endoscopic band ligation—not TXA 2
Important Caveats
Older meta-analyses suggested benefit 5, but these were based on small, methodologically weak trials 4. The HALT-IT trial from 2020 is the definitive study that supersedes all prior evidence—it was specifically designed to address the limitations of earlier research and enrolled over 10 times more patients than all previous trials combined 3.
One exception exists: TXA may be considered only for mild GI bleeding in patients with Hereditary Hemorrhagic Telangiectasia (HHT), based on low potential for harm in this specific population 2. For all other GI bleeding scenarios, avoid TXA.
The thrombotic risk is real and clinically significant—venous thromboembolic events nearly doubled with TXA use 3, making the risk-benefit ratio clearly unfavorable given the lack of mortality benefit.