Tranexamic Acid for Gastrointestinal Bleeding

Current Evidence on TXA for GI Bleeding

High-dose intravenous TXA shows no significant benefit in reducing mortality (RR 0.98, 95% CI 0.88-1.09) or rebleeding rates (RR 0.92, 95% CI 0.82-1.04) in gastrointestinal bleeding 1
The British Society of Gastroenterology explicitly suggests that use of tranexamic acid in acute lower GI bleeding should be confined to clinical trials, pending results of larger studies 2, 3
High-dose IV TXA is associated with increased risk of 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) 1
The European Association for the Study of the Liver strongly recommends against using TXA in patients with cirrhosis and active variceal bleeding 1

Standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized over TXA 1
For patients with acute GI bleeding, the British Society of Gastroenterology recommends early endoscopic intervention for diagnosis and treatment 2, 3
For patients on anticoagulants with GI bleeding, the British Society of Gastroenterology suggests interrupting direct oral anticoagulant therapy at presentation 3
For patients on anticoagulants with GI bleeding, the British Society of Gastroenterology recommends considering specific reversal agents (idarucizumab, andexanet) for life-threatening hemorrhage on DOACs 3

The risk-benefit profile is particularly unfavorable in patients with cirrhosis and variceal bleeding, where TXA should be avoided, according to the European Association for the Study of the Liver 1
All hospitals should have a GI bleeding lead and agreed pathways for management of acute GI bleeding, as recommended by the British Society of Gastroenterology 2, 3