Resumption of Anticoagulation After GI Bleeding: Is It a Good Idea?
Vanessa M. Shami, MD, FASGE, reviewing Tapaskar N, et al. Clin Gastroenterol Hepatol 2020 Nov 20.
Millions of individuals with atrial fibrillation are prescribed anticoagulants (warfarin or direct oral anticoagulants [DOACs]) to decrease the incidence of thromboembolic events. In a subset of patients who experience GI bleeding (GIB), anticoagulation management upon discharge is often arbitrary. This retrospective analysis assessed whether resuming anticoagulant use after GIB increases the risk of recurrent GIB.
The investigators used claims data from January 2008 through December 2017 for 2991 patients prescribed anticoagulants (warfarin, 1872 patients; rivaroxaban, 676; dabigatran, 293; apixaban, 250) and hospitalized for GIB. Of the patients taking warfarin prior to hospitalization, 46% (n=869) resumed warfarin following discharge compared to 43% (n=483) from the DOAC group who resumed DOAC after discharge. In the regression analysis modeling time-varying coefficients for anticoagulant use, warfarin resumption was associated with an increased risk of recurrent GIB (hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.43-3.14; P=.0002) compared to no anticoagulant resumption. In contrast, DOAC resumption (as a class) was not associated with increased risk of recurrent bleeding (HR, 1.43; 95% CI, 0.81-2.52; P=.22), although rivaroxaban was associated with increased risk of recurrent GIB (HR, 2.73; 95% CI, 1.43-5.20; P=.002). Resumption of both warfarin (HR, 0.61; 95% CI, 0.39-0.96; P=.033) and DOAC (HR, 0.52; 95% CI, 0.28-0.98; P=.044) as a class was associated with a decreased risk of thromboembolism.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
Tapaskar N, Ham SA, Micic D, Sengupta N. Restarting warfarin versus direct oral anticoagulants after major gastrointestinal bleeding and associated outcomes in atrial fibrillation: a cohort study. Clin Gastroenterol Hepatol 2020 Nov 20. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2020.11.029)