Locations and Mucosal Lesions Responsible for Major Gastrointestinal Bleeding in Patients on Warfarin or Dabigatran

Abstract

In a chronic NVAF population, D150 but not D110 is associated with increased major and life-threatening GI bleeding in comparison with warfarin. At both dabigatran doses, increased bleeding from the colorectum, in particular from angiodysplasia, is seen.

Major gastrointestinal bleeding and antithrombotics: Characteristics and management

“…There was a larger proportion of DOAC prescription among patients with a lower GI location than among those with an upper GI lesion location. A similar distribution was reported by Pannach et al[ 7 ] and by post-hoc analyses in pivotal trials[ 13 , 14 ]. Several reasons are given: Incomplete absorption of DOAC across the GI mucosa and a potential for topical drug activity leading to relevant concentrations of active drug in the lower GI tract[ 15 ], non-absorbed active DOAC being excreted into the feces[ 16 ].…”

“…Among patients undergoing GI investigations, a bleeding lesion was identified for 64.5%, which is higher than in other reports: 42%-44% in the prospective study by Pannach et al[ 7 ], 58.4% in the post-hoc study by Kolb et al[ 13 ] within the RELY study.…”

Risk Stratification of Angioectasia as a Cause of Gastrointestinal Bleeding: Untangling the Spider’s Web?

“…As noted by the authors, identification of high-and low-risk patient categories is one of the first steps toward defining appropriate endoscopic or medical management techniques with respect to rebleeding risk from AE. As cardiac comorbidities increase in an aging population, and anticoagulant and antiplatelet therapies become more prevalent, bleeding from AE will remain common [20]. Understanding the clinical risk factors related to bleeding and rebleeding is the first step in providing hypotheses related to the pathogenesis of gastrointestinal AE.…”

GI Bleeding Risk of DOACs Versus Warfarin: Is Newer Better?

“…This active drug in the distal bowel may promote GI bleeding more than warfarin, which is not activated in the bowel [7]. Secondly, there are reports that dabigatran is associated with esophagitis and gastric ulceration, suggesting the drug may directly injure the gastrointestinal mucosa.In this issue of Digestive Diseases and Sciences, Kolb et al [8] report a post hoc analysis of the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial (one of the landmark trials discussed above, this one comparing dabigatran to warfarin) where they re-reviewed the cases of suspected GI bleeding, collecting additional data including the causative lesions and the site and acuity of bleeding within the bowel. They could localize bleeding in approximately two-thirds of the cases, with 47% of those cases detected in the upper GI tract and 39% in the colon.…”

“…In this issue of Digestive Diseases and Sciences, Kolb et al [8] report a post hoc analysis of the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial (one of the landmark trials discussed above, this one comparing dabigatran to warfarin) where they re-reviewed the cases of suspected GI bleeding, collecting additional data including the causative lesions and the site and acuity of bleeding within the bowel. They could localize bleeding in approximately two-thirds of the cases, with 47% of those cases detected in the upper GI tract and 39% in the colon.…”