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Reducing upper digestive bleeding risk in patients treated with direct oral anticoagulants and concomitant infection
Andra-Iulia Suceveanu1, Adrian-Paul Suceveanu2, Irinel Parepa3
1Department of Gastroenterology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania.
Insights
Treating Helicobacter pylori infection alongside direct oral anticoagulants (DOACs) significantly reduces upper digestive bleeding risks and improves patient outcomes. This combined approach enhances the safety of DOAC therapy, particularly for high-risk individuals.
Area of Science:
- Gastroenterology
- Cardiology
- Internal Medicine
Background:
- Direct oral anticoagulants (DOACs) are crucial for preventing embolic cardiovascular events.
- Observational studies suggest that Helicobacter pylori (HP) infection may increase gastrointestinal bleeding risk in DOAC users.
- The impact of HP eradication on upper digestive bleeding (UDB) in DOAC patients requires further investigation.
Purpose of the Study:
- To compare upper digestive bleeding (UDB) rates in patients taking DOACs with and without concomitant anti-HP therapy.
- To evaluate the effectiveness of HP eradication in mitigating UDB severity and improving outcomes in DOAC users.
Main Methods:
- An observational retrospective study analyzed 260 patients treated with DOACs.
- 130 patients received concomitant HP infection treatment per Maastricht V/Florence consensus guidelines.
- Outcomes compared included bleeding severity, endoscopic treatment complexity, re-bleeding rates, surgical intervention, and mortality.
Main Results:
- HP-untreated patients had a higher risk of UDB (2.08 vs. 2.02).
- HP-untreated patients experienced more severe bleeding, required more complex endoscopic interventions, and had higher re-bleeding rates (OR 82.5).
- Surgical intervention and UDB-related mortality were significantly higher in HP-untreated DOAC users.
Conclusions:
- HP eradication therapy improves the safety profile of DOACs.
- Combining HP treatment with DOACs lowers UDB rates and enhances overall outcomes, especially in vulnerable patients.
- This strategy offers a significant benefit for patients requiring anticoagulation therapy.
Abstract:
Direct oral anticoagulants (DOACs) such as apixaban or dabigatran are excellent options in preventing embolic cardiovascular events. Observational studies have shown that gastrointestinal bleeding risks produced by DOACs could be lowered when correcting some host co-factors i.e. Helicobacter pylori (HP) infection. The upper digestive bleeding (UDB) rates in patients with DOAC indication and the usefulness of anti-HP therapy addition were compared. An observational retrospective study was conducted of medical records of 260 patients treated with DOACs, 130 of whom were concomitantly treated for HP infection in accordance with Maastricht V/Florence consensus. The severity of bleeding, the complexity of endoscopic treatment required to stop the bleeding, the re-bleeding rates, the surgical treatment indication and the overall mortality rates were compared between the groups. The risk of UDB was higher in HP-untreated patients in both types of DOACs used (respectively 2.08, 2.02). HP-untreated Forrest Ia/Ib/IIa and IIb DOACs patients had more severe bleedings compared with same class of HP-treated patients (P=0.007/0.005; 0.009/0.006; 0.048/0.005, 0.044/0.049, respectively). Endoscopic treatments such as adrenaline injections combined with metallic clip attachments were more frequently mandatory in HP-untreated DOACs patients for classes Ia/b and IIa (respectively, P=0.000/0.001, P=0.003/0.003). The re-bleeding rates were higher in HP-untreated patients with concomitant DOACs (OR 82.5; 95% CI 30.1-121.7; P=0.005). A history of peptic ulcer or UDB was associated with a 2.9-fold higher risk of UDB in HP-untreated compared with HP-treated patients, slightly increased for dabigatran compared with apixaban (RR 3.06, 2.72, P<0.5, respectively). Surgical intervention and the UDB-related mortality rates were higher in HP-untreated patients (P=0.041/0.044, P=0.007, respectively). HP-eradication treatment and bacterial clearance improve the safety profile of DOACs treatment, especially in fragile patients, in whom the UDB rates can be lowered, and the overall outcome can be enhanced by this combined approach.
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