Tranexamic Acid Should NOT Be Used for Gastrointestinal Bleeding
High-dose intravenous tranexamic acid does not reduce mortality or rebleeding in gastrointestinal bleeding and increases the risk of venous thromboembolism, and therefore should not be used outside of clinical trials. 1, 2
Evidence Against TXA in GI Bleeding
The most definitive evidence comes from the HALT-IT trial, which randomized 12,009 patients with acute GI bleeding to receive either high-dose TXA (1g loading dose followed by 3g over 24 hours) or placebo. This landmark study found:
- No mortality benefit: Death from bleeding occurred in 4% of both groups (RR 0.99,95% CI 0.82-1.18) 3
- No reduction in rebleeding: RR 0.92 (95% CI 0.82-1.04) 4
- Increased thrombotic complications: Venous thromboembolism was nearly doubled (RR 1.85,95% CI 1.15-2.98), with increased deep vein thrombosis, pulmonary embolism, and seizures 4, 3
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
Additional guideline positions include:
- The European Association for the Study of the Liver strongly recommends against TXA in cirrhotic patients with active variceal bleeding (strong recommendation based on high-certainty evidence) 1, 2
- The British Society of Gastroenterology states that TXA use in acute lower GI bleeding should be confined to clinical trials only 1, 2, 5
Why TXA Fails in GI Bleeding (Despite Success in Trauma)
While TXA reduces mortality in trauma and postpartum hemorrhage when given within 3 hours of injury, this benefit does not translate to GI bleeding. 1, 2 The pathophysiology differs fundamentally—trauma bleeding involves acute fibrinolysis at injury sites, whereas GI bleeding involves mucosal lesions where local hemostatic mechanisms and endoscopic/pharmacologic interventions are more relevant. 1
What About Low-Dose TXA?
Older, smaller trials using low-dose IV or enteral TXA showed potential benefits (RR 0.5 for rebleeding, RR 0.58 for surgery), but this evidence is of moderate certainty only and predates modern endoscopic therapy and high-dose proton pump inhibitors. 1, 4 Current evidence does not support routine use of low-dose TXA, and further research is needed before any recommendation can be made. 1
Correct Management Approach
Instead of TXA, prioritize:
- Resuscitation with restrictive transfusion strategy (target hemoglobin 7-9 g/dL in upper GI bleeding) 1
- Proton pump inhibitors and prompt endoscopic intervention for upper GI bleeding 2
- Vasoactive drugs, antibiotics, and endoscopic band ligation for variceal bleeding 1, 2
- Established pathways with a designated GI bleeding lead at each institution 2, 5
Critical Pitfalls to Avoid
- Do not extrapolate trauma data to GI bleeding—the disease processes are fundamentally different 1, 2
- Do not use TXA in cirrhotic patients with variceal bleeding—no benefit and increased VTE risk 1, 2
- Do not add TXA to patients on anticoagulants with GI bleeding—focus on withholding anticoagulation and considering reversal agents instead 2
- Historical meta-analyses suggesting benefit are misleading—when limited to low-risk-of-bias trials, the treatment benefit disappears 5
Exception: Hereditary Hemorrhagic Telangiectasia Only
TXA may be considered only for mild GI bleeding in Hereditary Hemorrhagic Telangiectasia (HHT) patients, based on low potential for harm in this specific population. For moderate-to-severe GI bleeding in HHT requiring transfusion, systemic bevacizumab is preferred, not TXA. 1