Is tranexamic acid (TXA) indicated for severe upper Gastrointestinal (GI) bleeding?

Tranexamic Acid Should NOT Be Used for Upper GI Bleeding

Do not use high-dose intravenous tranexamic acid for upper gastrointestinal bleeding—it provides no mortality or rebleeding benefit and significantly increases thromboembolic complications. 1, 2

Evidence-Based Recommendation

The most recent high-quality evidence from the HALT-IT trial (which informed current 2025 guidelines) definitively demonstrates that high-dose IV tranexamic acid:

• Shows no mortality reduction (RR 0.98,95% CI 0.88-1.09) 1, 2
• Does not decrease rebleeding rates (RR 0.92,95% CI 0.82-1.04) 1, 2
• Does not reduce need for surgical intervention (RR 0.91,95% CI 0.76-1.09) 1
• Significantly increases 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) 2

Guideline Consensus

The American College of Gastroenterology explicitly does not recommend high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk. 1

The British Society of Gastroenterology recommends that TXA use in acute lower GI bleeding should be confined to clinical trials only. 2

Critical Caveat: Older Studies Are Misleading

While older meta-analyses from 2008 and 2021 3, 4 suggested potential mortality benefits, these analyses:

• Included small, methodologically weak trials conducted before modern endoscopic therapy and proton pump inhibitors were standard 3
• Did not capture the thromboembolic risks identified in the large, high-quality HALT-IT trial 1, 2
• Should not guide current practice given the definitive evidence from HALT-IT

Special Populations Where TXA Is Contraindicated

Cirrhotic Patients with Variceal Bleeding

The European Association for the Study of the Liver provides a strong recommendation against TXA use in cirrhotic patients with active variceal bleeding due to:

• No benefit in controlling esophageal variceal hemorrhage 1
• Increased risk of venous thromboembolism 1, 2

Standard Therapy Instead

For variceal bleeding, use:

• Vasoactive drugs (octreotide, terlipressin) 1
• Prophylactic antibiotics 1
• Endoscopic band ligation 1

What About Low-Dose TXA?

Evidence for low-dose IV or enteral TXA shows potential benefits (RR 0.5 for rebleeding, 95% CI 0.33-0.75), but this is moderate-certainty evidence only. 1 Current guidelines do not support routine use, and further research is needed before any recommendation can be made for low-dose regimens as rescue therapy. 1

The Only Exception: Hereditary Hemorrhagic Telangiectasia

TXA is recommended only for mild GI bleeding in HHT patients based on low potential for harm. For moderate-to-severe GI bleeding in HHT requiring transfusion, systemic bevacizumab is preferred, not tranexamic acid. 1

Correct Management Approach

Prioritize standard evidence-based management:

• Resuscitation with restrictive transfusion strategy (target hemoglobin 7-9 g/dL) 1
• Early endoscopic intervention for diagnosis and treatment 2
• Appropriate pharmacological therapy (proton pump inhibitors for non-variceal bleeding, vasoactive drugs for variceal bleeding) 1, 2
• Reversal agents for anticoagulant-associated bleeding when indicated (idarucizumab, andexanet) 2

Common Pitfall to Avoid

Do not extrapolate TXA's proven benefits in trauma and surgical bleeding to GI bleeding—disease-specific evidence clearly shows no benefit and significant harm in the GI bleeding context. 1