Outcomes of upper gastrointestinal bleeding are similar between direct oral anticoagulants and vitamin K antagonists

Abstract

Summary Background The increased risk of upper gastrointestinal bleeding (UGIB) related to direct oral anticoagulants (DOACs) as compared to vitamin K antagonists (VKA) remains debated. Aims To describe the epidemiology and outcomes of UGIB in patients treated with oral anticoagulants. Methods A prospective, multicentre study in French general hospitals enrolled all consecutive patients with UGIB during one year. Patients treated with oral anticoagulants were retrieved from the cohort. Main outcomes were mortality and rebleeding during the first 6 weeks and need for non‐endoscopic treatment (surgery or interventional radiology). Results Among the 2498 patients included, 475 (19%) had an oral anticoagulant, mostly with VKA (267 patients [56.2%]). Baseline characteristics were similar between the groups except for renal failure and cirrhosis that were more prevalent in the VKA group. Gastroscopy was normal in 73 patients (15.3%); peptic lesions were the main cause of UGIB (n = 233, 49%). Endoscopic treatment was performed in 128 patients (26.9%), leading to bleeding resolution in 74% (n = 95). Mortality rate at 6 weeks was 12.4% (59 patients), and was higher in the VKA group compared to DOACs (16.1% vs 7.8%, P < 0.01). By multivariate analysis, only the Charlson index ≥ 5 and UGIB occurrring in in‐patients were independently associated with mortality. Rebleeding (56 patients [11.8%]) and need for non‐endoscopic treatment (18 patients [3.8%]) were not associated with the type of anticoagulant. Conclusion DOACs do not alter outcomes of UGIB as compared to VKA. Comorbidities and associated treatment are the most important factors worsening the prognosis of UGIB.

Severity of gastrointestinal bleeding is similar between patients receiving direct oral anticoagulants or vitamin K antagonists

“…In terms of severity of the GIB, we did not find significant differences between AVK and DOAC groups. Also, there were no differences on the Hb level on admission, the drop of Hb, the number of PRBC units transfused, and days in hospital, in accordance with a recent observational prospective study in upper GI bleeding (11) and a systematic review (19). These data are in contrast with two retrospective studies in patients with GIB treated with DOAC that show that this group had fewer hospitalizations and required fewer transfusions when compared to VKA (20)(21).…”

“…We included patients presenting to the ED with GIB, both upper and lower, and this population mainly consisted of elderly patients, frequently suffering from cardiovascular comorbidities, and mostly receiving anticoagulation for NVAF. The mean age of our patients was similar to patients on DOAC in a real-life study performed in Spain (12), although that study was designed to compare the incidence of major bleeding events between DOAC and VKA and not severity, but also to other recently published real-life studies of GIB in patients under anticoagulation comparing clinical and endoscopic features, aetiology and severity (6,10,11). Comparing comorbidities, we found a higher prevalence of severe CKD in patients on VKA, and higher prevalence of pre-existing cerebrovascular disease in patients on DOAC, probably as a consequence of actual recommendations in clinical practice (13)(14).…”

“…DOAC therapy has been associated with higher incidence of GIB (4, 5) but information regarding the severity and aetiology of GIB in real life patients receiving DOAC compared to VKA is scarce. Most available data derive from observational cohorts or retrospective studies (6)(7)(8)(9)(10), although a recent study has prospectively compared clinical outcomes in patients receiving DOAC vs. VKA, but only in patients presenting with upper GIB (11). We included patients presenting to the ED with GIB, both upper and lower, and this population mainly consisted of elderly patients, frequently suffering from cardiovascular comorbidities, and mostly receiving anticoagulation for NVAF.…”

Vitamin-K Antagonists vs. Direct Oral Anticoagulants on Severity of Upper Gastrointestinal Bleeding: A Retrospective Analysis of Italian and UK Data

“…Indeed, we take into account the caution that must be used when interpreting these results, considering that other authors already stressed the impact that comorbidities might exert on the outcomes of a bleeding event. On this matter, a French prospective multicenter study evaluated patients with UGIB under oral anticoagulants and found that DOACs, when compared to VKA, did not alter their outcomes (rebleeding in the first 6 weeks, need for surgery/interventional radiology, mortality) and they commented that comorbidities are one of the most important factors affecting UGIB prognosis [ 57 ]. Similarly, Di Minno and colleagues, in their review, discussed how severity of comorbidities can exert a greater impact on the risk of GIB than the type of antithrombotic agent used [ 58 ].…”

Addendum zur S2k-Leitlinie Gastrointestinale Blutungen der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS)

“…In den letzten Jahren sind mehrere größere Studien erschienen, die nicht nur die Klassen der DOAK mit Vitamin-K-Antagonisten, sondern auch die einzelnen Präparate verglichen haben. In einer prospektiven multizentrischen Studie aus Frankreich mit 2498 Patienten [14], die mit einer oberen GI-Blutung innerhalb eines Jahres aufgenommen wurden, nahmen 19 % eine orale Antikoagulation ein, 56,2 % davon Vitamin-K-Antagonisten. Der Vergleich zwischen den DOAK und Vitamin-K-Antagonisten ergab keine signifikanten Unterschiede für die Reblutung, allerdings gab es einen Trend zu einem etwas besseren Überleben bei Patienten unter DOAK (OR 0,53 [0,27 -1,04], p = 0,068).…”