Tranexamic Acid for Gastrointestinal Bleeding

Efficacy and Safety

High-dose intravenous tranexamic acid shows no benefit in reducing mortality or rebleeding in gastrointestinal bleeding, and increases the risk of thromboembolic events, based on high-certainty evidence from the HALT-IT trial 1, 2, 3
The American College of Gastroenterology does not recommend high-dose IV TXA for gastrointestinal bleeding due to lack of benefit and increased thrombotic risk 1, 3
No significant difference was found in mortality (RR 0.98, 95% CI 0.88-1.09), rebleeding rates (RR 0.92, 95% CI 0.82-1.04), or need for surgical intervention (RR 0.91, 95% CI 0.76-1.09) with high-dose IV TXA 3
Evidence for low-dose IV or enteral TXA is of moderate certainty and shows potential benefits, including reduction in rebleeding (RR 0.5, 95% CI 0.33-0.75) and decreased need for surgical intervention (RR 0.58, 95% CI 0.38-0.88) 3

The European Association for the Study of the Liver recommends that TXA should not be used in patients with cirrhosis and active variceal bleeding (strong recommendation) 4
The British Society of Gastroenterology suggests that use of TXA in acute lower GI bleeding should be confined to clinical trials 5
For variceal bleeding, standard therapy with vasoactive drugs, antibiotics, and endoscopic band ligation should be used, and TXA should be avoided due to lack of benefit and increased thrombotic risk 6, 4

For all GI bleeding, standard management with resuscitation, endoscopic therapy, and pharmacological treatments should be prioritized, and high-dose IV TXA should not be used due to lack of benefit and increased thrombotic risk 1, 3, 5
For refractory non-variceal bleeding, current evidence does not support routine use of TXA, and further research is needed on the potential role of low-dose IV or enteral TXA as rescue therapy 1, 3

Tranexamic acid has shown benefits in trauma and surgical bleeding, but this does not translate to gastrointestinal bleeding, highlighting the importance of disease-specific evidence rather than extrapolating from other clinical scenarios 7, 8

For patients with cirrhosis, tranexamic acid has shown no benefit in controlling esophageal variceal hemorrhage and may increase the risk of venous thromboembolism events 9
A recent international multicenter, randomized, double-blind, placebo-controlled trial showed the risk of VTE events to be higher in patients with cirrhosis receiving tranexamic acid 9
For patients with bleeding disorders of unknown cause, tranexamic acid is commonly used for prophylaxis in minor procedures, major procedures, and deliveries, but evidence quality is very low 10

For cirrhotic patients undergoing invasive procedures, routine tranexamic acid use is discouraged, as recommended by the European Association for the Study of the Liver, with a strong recommendation against its use in variceal bleeding 11
Tranexamic acid is recommended for mild GI bleeding in Hereditary Hemorrhagic Telangiectasia (HHT) patients only, based on low potential for harm, while for moderate-to-severe GI bleeding in HHT requiring transfusion, systemic bevacizumab is the preferred therapy, not tranexamic acid 12
Resuscitation with restrictive transfusion strategy (target hemoglobin 7-9 g/dL in upper GI bleeding) is recommended as part of standard therapy, as suggested by the Journal of Hepatology 11

The European Association for the Study of the Liver provides a strong recommendation against the use of tranexamic acid in cirrhotic patients with variceal bleeding, due to lack of benefit and increased risk of venous thromboembolism 11

Historical studies suggesting benefit of tranexamic acid were performed before the routine use of high‑dose proton‑pump inhibitors and modern endoscopic techniques, limiting their applicability to current practice. 13

The British Society of Gastroenterology advises that tranexamic acid should be used only within clinical trials for patients with acute lower gastrointestinal bleeding, reflecting insufficient evidence of benefit. 13
This guidance also highlights concerns about potential harm, including thromboembolic complications, in this patient population. 13

The FDA label for tranexamic acid lists thromboembolic events (arterial, venous, embolic) as a recognized adverse effect of overdose. 13
The FDA label also warns that hypotension may occur with tranexamic acid overdose. 13