Want To Take Out Polyps in Anticoagulated Patients? New Data Indicate Apixaban Is the Drug To Be On
Douglas K. Rex, MD, MASGE, reviewing Lau LH, et al. Gut 2021 Feb 22.
This retrospective cohort study evaluated postpolypectomy bleeding and thromboembolism risks with warfarin, apixaban, dabigatran, and rivaroxaban use in Hong Kong public hospitals between January 2012 and June 2020. The authors identified 3887 patients who underwent colonoscopic polypectomy and were being treated with oral anticoagulation therapy (warfarin, 2222; dabigatran, 604; rivaroxaban, 526; and apixaban, 510). The primary outcome was clinically significant delayed postpolypectomy bleeding, defined as the need for repeat colonoscopy with hemostasis to control bleeding within 30 days after index colonoscopy. The secondary outcomes were blood transfusion and thromboembolic events within 30 days.
In multivariate analyses comparing direct oral anticoagulants (DOACs) to warfarin, apixaban reduced the need for repeat colonoscopy by 61%, dabigatran was not different, and rivaroxaban increased the bleeding risk by 66%. Relative to warfarin, the risk of bleeding in patients receiving apixaban was 73% lower in patients aged 70 years or older and 63% lower in those with a HAS-BLED score <3. Apixaban also lowered the risk of bleeding from both right- and left-sided polyps in the absence of concurrent antiplatelet agents and at all doses.
Compared to the other 2 DOACs, apixaban was associated with lower bleeding risk in patients aged 70 years or older and in patients without concurrent use of antiplatelet agents.
Apixaban also lowered the thromboembolism risk by 79% compared to warfarin. Dabigatran and rivaroxaban were not different than warfarin for thromboembolic risk.
Detailed data on polyp size, morphology, endoscopic resection method, and clipping rates were not available across the entire study. When available, right-sided location, endoscopic resection using electrocautery, warfarin use, and advanced stage were independent risk factors of bleeding according to multivariate analyses. However, these factors did not differ between warfarin and DOAC groups.
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.
Lau LH, Guo CL, Yip TC, et al. Risks of post-colonoscopic polypectomy bleeding and thromboembolism with warfarin and direct oral anticoagulants: a population-based analysis. Gut 2021 Feb 22. (Epub ahead of print) (https://doi.org/10.1136/gutjnl-2020-323600)