Tranexamic Acid Does NOT Stop GI Bleeding and Should NOT Be Used
Do not use tranexamic acid for gastrointestinal bleeding—high-dose IV TXA provides no mortality or rebleeding benefit and increases venous thromboembolism risk. 1, 2
The Definitive Evidence Against TXA in GI Bleeding
The HALT-IT trial (2020), the largest and highest-quality study on this question with 12,009 patients, definitively showed that high-dose tranexamic acid (1g loading dose followed by 3g over 24 hours) does not reduce death from bleeding (4% in both TXA and placebo groups, RR 0.99,95% CI 0.82-1.18). 3 Critically, TXA nearly doubled the risk of venous thromboembolism (0.8% vs 0.4%, RR 1.85,95% CI 1.15-2.98) without any clinical benefit. 3
Current Guideline Recommendations
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 European Association for the Study of the Liver provides a strong recommendation against using TXA in cirrhotic patients with active variceal bleeding. 1, 2
The British Society of Gastroenterology states that TXA use in acute lower GI bleeding should be confined to clinical trials only. 2, 4
Why Earlier Studies Were Misleading
Earlier meta-analyses suggested a 40% mortality reduction, but this benefit disappeared when analysis was limited to trials with low risk of bias. 4 Historical studies were conducted before routine use of high-dose proton pump inhibitors and modern endoscopic therapy, making them irrelevant to current practice. 4 The 2008 systematic review showing mortality benefit included only 1,754 patients with significant methodological limitations and only one trial that used endoscopic treatments or PPIs. 5
What Actually Works for GI Bleeding
For upper GI bleeding: Use proton pump inhibitors and prompt endoscopic intervention as the cornerstone of treatment. 2
For variceal bleeding: Use standard therapy with vasoactive drugs (octreotide or terlipressin), prophylactic antibiotics, and endoscopic band ligation—not TXA. 1, 2
For lower GI bleeding: Follow established pathways with resuscitation and endoscopic/radiological intervention as indicated. 2
The One Narrow Exception
For mild GI bleeding in Hereditary Hemorrhagic Telangiectasia (HHT) patients only, TXA may be considered based on low potential for harm, but for moderate-to-severe GI bleeding requiring transfusion in HHT, systemic bevacizumab is preferred over TXA. 1
Critical Pitfall to Avoid
Do not extrapolate TXA's proven benefits in trauma and surgical bleeding to GI bleeding—this is disease-specific evidence showing lack of efficacy. 1 While TXA reduces mortality in trauma when given within 3 hours of injury (1g over 10 minutes followed by 1g over 8 hours), this benefit does not translate to GI bleeding. 2