Is tranexamic acid (TXA) recommended for patients presenting with upper gastrointestinal (GI) bleeding?

Tranexamic Acid is NOT Recommended for Upper GI Bleeding

The American College of Gastroenterology explicitly recommends against using high-dose IV tranexamic acid for upper gastrointestinal bleeding due to lack of benefit and increased thrombotic risk. 1

Why TXA Should Be Avoided

The evidence against TXA use in upper GI bleeding is compelling:

• High-dose IV TXA provides no reduction in rebleeding rates and fails to demonstrate mortality benefit in modern clinical practice, with nearly 50% of patients in the HALT-IT cohort having suspected variceal bleeding 1

• TXA significantly increases thrombotic complications, including:

  • Deep vein thrombosis (relative risk 2.01) 1
  • Pulmonary embolism (relative risk 1.78) 1
  • Seizures (relative risk 1.73) 2

• The pathophysiology of GI bleeding differs fundamentally from traumatic hemorrhage, making trauma data (like CRASH-2) inapplicable to GI bleeding 1

Critical Distinction: Dose Matters

While older meta-analyses suggested potential mortality benefits 3, 4, 5, these studies have critical limitations:

• Most were conducted before modern endoscopic therapy and high-dose proton pump inhibitors became standard 6
• Studies were too small to adequately assess thromboembolic events 6
• Current guidelines state that further studies are necessary before TXA can be recommended as routine therapy 6

The most recent high-quality evidence shows that extended-use high-dose IV TXA does not reduce mortality (RR 0.98,95% CI 0.88-1.09) or bleeding but does increase adverse events 2

What to Do Instead: Evidence-Based Management Algorithm

Immediate resuscitation:

• Use restrictive transfusion strategy targeting hemoglobin 7-9 g/dL 1

Definitive treatment:

• Early endoscopic intervention for diagnosis and treatment remains first-line 1, 6
• Following successful endoscopic therapy, administer high-dose PPI therapy: 80 mg omeprazole stat followed by 8 mg/hour infusion for 72 hours 1, 6

For variceal bleeding specifically:

• Use vasoactive drugs, antibiotics, and endoscopic band ligation 1
• The European Association for the Study of the Liver strongly recommends against TXA in patients with cirrhosis and active variceal bleeding 1
• Transfusion of blood products can paradoxically increase portal pressure and worsen bleeding in cirrhotic patients 1

Special Exception: Hereditary Hemorrhagic Telangiectasia Only

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 1

• Dosing for HHT: oral TXA 500 mg twice daily, gradually increasing to 1000 mg four times daily 1

Common Pitfalls to Avoid

• Do not extrapolate trauma or surgical bleeding data to GI bleeding—the pathophysiology is fundamentally different 1
• Do not use TXA in cirrhotic patients undergoing procedures due to risk of disrupting the fragile fibrinolytic balance 1
• Standard coagulation tests do not reflect true hemostatic capacity in cirrhosis 1
• For lower GI bleeding, the British Society of Gastroenterology suggests TXA use should be confined to clinical trials only 1, 6