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Review Article: Gastrointestinal Bleeding Risk with Direct Oral Anticoagulants
Robert Benamouzig1, Maxime Guenoun2, David Deutsch3
1Department of Gastroenterology and Digestive Oncology, AP-HP Avicenne Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000, Bobigny, France. robert.benamouzig@avc.aphp.fr.
Insights
Direct oral anticoagulants (DOACs) do not increase major gastrointestinal bleeding risk compared to vitamin K antagonists (VKAs). DOAC-related gastrointestinal bleeding is often less severe and manageable, supporting their continued use.
Area of Science:
- Cardiology and Gastroenterology
- Pharmacology and Therapeutics
Background:
- Direct oral anticoagulants (DOACs) offer a favorable safety profile but their gastrointestinal (GI) bleeding risk versus vitamin K antagonists (VKAs) is debated.
- Understanding the comparative GI bleeding risk and management strategies for DOACs is crucial for clinical practice.
Purpose of the Study:
- To provide a focused overview of the gastrointestinal bleeding risk associated with dabigatran, rivaroxaban, apixaban, and edoxaban.
- To discuss the management of DOAC-associated gastrointestinal bleeding.
Main Methods:
- A comprehensive review of published studies was conducted.
- Included studies encompassed randomized controlled trials (RCTs), retrospective database studies, and prospective cohort studies reporting on DOACs and GI bleeding outcomes.
Main Results:
- Evidence indicates no significant difference in major GI bleeding risk between DOACs and VKAs.
- GI bleeding in DOAC patients appears less severe, requiring less intensive management.
- Common causes include gastroduodenal ulcers (upper GI) and diverticula (lower GI). Risk factors include advanced age, alcohol use, hypertension, and organ dysfunction.
Conclusions:
- DOACs as a class do not elevate the risk of major GI bleeding compared to VKAs.
- This finding supports the continued use of DOACs across various anticoagulant indications.
- Awareness of risk factors and appropriate management strategies are essential for DOAC-treated patients.
Purpose:
Although direct oral anticoagulants (DOACs) are associated with an overall favourable safety profile, the risk of gastrointestinal bleeding with DOACs compared with vitamin K antagonists (VKAs) remains controversial. Accordingly, we aimed to provide a focused overview of the risk of gastrointestinal bleeding associated with dabigatran, rivaroxaban, apixaban and edoxaban and its management.
Methods:
We reviewed published studies reporting on DOACs with gastrointestinal bleeding as an outcome, including randomised controlled trials (RCTs), retrospective database studies and large-scale prospective cohort studies.
Results:
Cumulative evidence confirms no notable difference in major gastrointestinal bleeding risk between DOACs and VKAs. Moreover, gastrointestinal bleeding in DOAC-treated patients seems less severe and requires less intensive management. The main cause of upper gastrointestinal bleeding in DOAC-treated patients appears to be gastroduodenal ulcers, whereas lower gastrointestinal bleedings are mainly due to diverticula followed by angiodysplasia and haemorrhoids. The lack of head-to-head RCTs with DOACs precludes drawing conclusions on the DOAC with the lowest gastrointestinal bleeding risk. Prescribing physicians should be aware of risk factors for DOAC-related gastrointestinal bleeding (e.g. age > 65, heavy alcohol use, uncontrolled hypertension, hepatic or renal dysfunction, active cancer, anaemia) and adopt preventive measures accordingly. Management of DOAC-associated major gastrointestinal bleeding involves temporary discontinuation of the DOAC, investigation of the bleeding source and treatment of bleeding with fluid resuscitation combined with transfusion and endoscopic haemostasis.
Conclusion:
DOACs as a class do not increase the risk of major gastrointestinal bleeding compared to VKAs, which supports their continued use for different anticoagulant indications.
