Outcomes Associated With Resuming Direct Oral Anticoagulant Therapy Following Admission for a Gastrointestinal Bleed

Abstract

Background: Although direct oral anticoagulants (DOACs) carry a lower bleeding risk compared with warfarin, gastrointestinal bleeds (GIB) are a known complication. There are limited data observing outcomes associated with resuming DOACs following a GIB. Objective: The purpose of this study was to evaluate practice patterns and clinical outcomes of patients admitted with an index GIB while receiving DOAC therapy. Methods: This retrospective, single-system study included adult patients receiving DOAC therapy prior to admission and hospitalized with an index GIB between January 1, 2013, and October 31, 2018. Patient exclusion criteria were a history of immune thrombocytopenia purpura or inflammatory bowel disease; discharge to hospice; leaving against medical advice; or death during hospitalization. The primary objective was 90-day readmission for a recurrent GIB. Results: There were 57 patients included for analysis; 37 patients had DOAC therapy held >7 days, 18 patients resumed DOAC therapy within 7 days, and 2 patients switched to warfarin. The majority of patients received rivaroxaban (59.6%) prior to admission for atrial fibrillation (71.9%), were admitted with a major GIB (66.7%), and required a blood transfusion (61.4%). The rates of recurrent GIB were 2.5% (n = 1) and 5.6% (n = 1) for those who had their DOAC held and resumed, respectively ( P = 0.83). Mortality within 12 months of discharge occurred in 4 patients (10.8%) who had their DOAC held and 4 patients (22.2%) who resumed DOAC therapy ( P = 0.28). Conclusion and Relevance: Resuming anticoagulation within 7 days of admission for an index GIB was not associated with a recurrent GIB within 90 days of discharge.

Re-starting anticoagulation and antiplatelets after gastrointestinal bleeding: A systematic review

“… 12 There was a 3% increase in patients who experienced a recurrent GIB after the resumption of DOACs. 12 , 27 Proietti et al focused on dabigatran and found that patients who were started on dabigatran had a reduced risk for recurrent GIB compared to those who started on warfarin. 18 Smit and Gelder reported that 49% of dabigatran users restarted anticoagulation after significant bleeding, and the risk of ischemic stroke and all-cause mortality decreased.…”

“… 30 Other studies, however, have reported recurrent GIB issues associated with rivaroxaban. 17 , 27 , 30 Valanejad et al demonstrated that rivaroxaban was the only DOAC that increased the risk of recurrent GIB. 27 Overall, most research reports that the resumption of DOACs reduces the risk of thromboembolism and all-cause mortality with a selective increase in recurrent GIBs.…”

“… 17 , 27 , 30 Valanejad et al demonstrated that rivaroxaban was the only DOAC that increased the risk of recurrent GIB. 27 Overall, most research reports that the resumption of DOACs reduces the risk of thromboembolism and all-cause mortality with a selective increase in recurrent GIBs. 12 , 17 , 19 , 28 The results were relatively similar when comparing DOACs with warfarin use, but a benefit of the DOACs with resuming treatment post-GIB is the predictability and reduced monitoring that is typically associated with DOACs as compared to warfarin.…”

“…25 On average, rebleeding occurred in 11.6% of patients restarted on warfarin and 5.7% of patients who were not restarted; however, the studies found that these differences were not statistically significant. 17,19,[22][23][24]26,27 Although it is assumed that patients who do not resume anticoagulants are at a lower risk of rebleeding and bleeding-related complications, Majeed et al demonstrated that these patients would require closer monitoring and shorter follow-up (92 weeks) as compared to those who were restarted on VKAs (142 weeks, p < 0.001). 26 The rate of recurrent bleed is high whether the patient is resumed on anticoagulants or not, with bleeding occurring at a median of 24 weeks in those that were resumed on anticoagulants and 23 weeks in patients that were not.…”

Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update

“…High quality prospective studies should be prioritized to get direct data from patients. Two systematic reviews showed survival advantage after anticoagulant resumption, no RCT or prospective study has been published, but six retrospective studies were found [33][34][35][36][37][38]. Anticoagulant resumption increased the rate of GI bleeding and decreased the rate of thromboembolism, with a net benefit on mortality [38].…”