scholarly journals Management of risk factors for gastrointestinal bleeding in patients receiving anticoagulant therapy

2021 ◽  
Vol 26 (8) ◽  
pp. 4635
Author(s):  
N. V. Bakulina ◽  
S. V. Tikhonov ◽  
N. B. Lishchuk ◽  
A. B. Karaya
Keyword(s):  
Risk Factors ◽  
Gastrointestinal Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Gastrointestinal Diseases ◽  
Thromboembolic Events ◽  
Antiinflammatory Drugs ◽  
Patient Profile ◽  
Increased Risk

Direct oral anticoagulants (DOACs) are used to prevent and treat thrombosis and thromboembolic events in patients with various diseases. Despite its high efficacy and safety, DOAC therapy is accompanied by increased risk of hemorrhage, including gastrointestinal bleeding. Bleeding risk depends on individual patient profile and their risk factors. An increased risk of bleeding is associated with manifesting effect of DOACs on existing mucosal defects, active Helicobacter pylori infection. To reduce the risk of gastrointestinal bleeding in clinical practice, changing of following modifiable risk factors is required: H. pylori eradication; dose-adjusted DOAC therapy; prophylactic proton pump inhibitors (PPIs) administration to patients with HAS-BLED score ≥3, receiving dual or triple antithrombotic therapy, taking DOACs in combination with non-steroidal antiinflammatory drugs, to those with upper gastrointestinal diseases. In addition to PPIs, patients may be prescribed with rebamipide, bismuth tripotassium dicitrate, ursodeoxycholic acid. DOAC rivaroxaban (Xarelto®) has pharmacokinetic and pharmacodynamic advantages, a convenient single dosing regimen and a favorable safety profile, which provides effective protection against thrombosis and thromboembolic events in combination with low risk of gastrointestinal bleeding.

Abstract 15237: Predictors of Intracranial and Gastrointestinal Bleeding in Cirrhosis With Use of Direct Oral Anticoagulants: A Large Population Based Study

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Muhammad U Butt ◽  
Aun R Shah ◽  
Osama Hamid ◽  
Sara Ghoneim ◽  
Maham Malik
Keyword(s):  
Risk Factors ◽  
Gastrointestinal Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Large Population ◽  
Bleeding Risk ◽  
Population Based ◽  
Snomed Ct ◽  
Risk Of Bleeding ◽  
Cirrhotic Patients

Introduction: Use of Direct Oral Anticoagulants (DOACs) in patients with cirrhosis remains controversial, as the studies demonstrating safety of DOACs excluded these patients. Hypothesis: To determine the predictors of Intracranial and Gastrointestinal bleeding in cirrhosis with use of DOACs. Methods: We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED CT), we identified adults with liver cirrhosis, intracranial and gastrointestinal bleeding. Risk factors known to be associated with bleeding such as alcohol abuse, NSAIDs, CKD and advanced age were collected. Bleeding risk with DOAC use was compared with coumadin. Univariable and multivariable logistic regression analyses were performed to investigate strongest predictors Results: Out of 61.4 million active adult patients in the database, 468,580 patients (0.61%) had documented cirrhosis. 9.14 % and 3.14 % of the cirrhotic patients were on DOACs and coumadin, respectively. In cirrhotic patients, there was higher composite risk of ICH or GIB if they were on DOACs (35.47% vs 21.24 % OR 2.04 [2.01-2.07]), used NSAIDs (31.15% vs 23.63% OR 1.46 [1.44-1.48]), had CKD (32.61% vs 25.04 %, OR 1.45 [1.42-1.47]), or abused alcohol (36.22% vs 23.57%, OR 1.84 [1.81- 1.87]). Risk of bleeding was higher with DOACs as compared to coumadin (35.47% vs 22.81%: p< 0.001). In Multivariable model CKD modified composite bleeding risk of ICH or GIB after adjustment for other risk factors. A cirrhotic patient on DOAC had higher risk of bleeding with CKD (OR 2.29 [(2.22-2.37)]) than without CKD (OR 1.66 [(1.63-1.69)]). This interaction was found to be statistically significant. Similar trend was noticed with use of coumadin. Conclusions: Major bleeding risk in cirrhosis was significantly higher with use of DOACs as compared to warfarin. This risk was highest in patients with CKD.

scholarly journals Current Recommendations for the Management of Cancer-Associated Venous Thromboembolism

2021 ◽  
Vol 7 (2) ◽  
pp. 27-38
Author(s):  
Katalin Makó
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Term Treatment ◽  
Long Term Treatment ◽  
High Bleeding Risk ◽  
Cancer Associated Thrombosis

Abstract Cancer-associated thrombosis (CAT) is a major cause of death in oncological patients. The mechanisms of thrombogenesis in cancer patients are not fully established, and it seems to be multifactorial in origin. Also, several risk factors for venous thromboembolism (VTE) are present in these patients such as tumor site, stage, histology of cancer, chemotherapy, surgery, and immobilization. Anticoagulant treatment in CAT is challenging because of high bleeding risk during treatment and recurrence of VTE. Current major guidelines recommend low molecular weight heparins (LMWHs) for early and long-term treatment of VTE in cancer patients. In the past years, direct oral anticoagulants (DOACs) are recommended as potential treatment option for VTE and have recently been proposed as a new option for treating CAT. This manuscript will give a short overview of risk factors involved in the development of CAT and a summary on the recent recommendations and guidelines for treatment of VTE in patients with malignancies, discussing also some special clinical situations (e.g. renal impairment, catheter-related thrombosis, and thrombocytopenia).

scholarly journals Slightly elevated international normalized ratio predicts bleeding episodes in patients treated with direct oral anticoagulants

2020 ◽  
Vol 48 (6) ◽  
pp. 030006051989443
Author(s):  
Priya Bhardwaj ◽  
Louise Breum Petersen ◽  
Tomas Sorm Binko ◽  
Jan Roland Petersen ◽  
Gitte Gleerup Fornitz
Keyword(s):  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Bleeding Risk ◽  
International Normalized Ratio ◽  
Direct Factor ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Direct Factor Xa Inhibitors ◽  
Bleeding Episodes

Introduction Patients treated with direct oral anticoagulants (DOACs) are at increased bleeding risk. It is therefore of increasing interest to identify predictors of bleeding episodes to increase safety during treatment with DOACs. Methods This retrospective cohort study systematically reviewed medical records of 235 patients treated with either apixaban, rivaroxaban or dabigatran for non-valvular atrial fibrillation or venous thromboembolism and collected data on the international normalized ratio (INR) and all bleeding episodes. Results INR ≥ 1.5 was significantly associated with increased risk of minor and major bleeding events in patients treated with direct factor Xa inhibitors. This association was not present in patients treated with dabigatran. However, a high negative predictive value was identified for INR < 1.5 for all drugs. The relative risks of bleeding episodes in patients with INR ≥ 1.5 and INR < 1.5 were 5.1 and 0.20, respectively. Conclusions Our results demonstrate a strong correlation between INR and risk of bleeding episodes during DOAC treatment. INR < 1.5 was a strong negative predictor for low bleeding risk independent of indication or choice of drug, and INR ≥ 1.5 was associated with increased risk of bleeding episodes in patients treated with direct factor Xa-inhibitors.

scholarly journals A prospective multicenter observational study evaluating the risk of periendoscopic events in patients using anticoagulants: the Osaka GIANT Study

2019 ◽  
Vol 07 (02) ◽  
pp. E104-E114 ◽  
Author(s):  
Takuya Inoue ◽  
Hideki Iijima ◽  
Takuya Yamada ◽  
Yuji Okuyama ◽  
Kanae Takahashi ◽  
...  
Keyword(s):  
Gastrointestinal Bleeding ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Endoscopic Biopsy ◽  
Thromboembolic Events ◽  
Endoscopic Procedures ◽  
Multicenter Observational Study ◽  
Number Of Patients ◽  
Duration Of Hospitalization

Abstract Background and study aims An increasing number of patients have been using anticoagulants including anti-vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs); however, in patients using anticoagulants, limited data are available with regard to the risks of gastrointestinal bleeding and thromboembolic events during the peri-endoscopic period. We aimed to evaluate the peri-endoscopic bleeding and thrombotic risks in patients administered VKAs or DOACs. Patients and methods Consecutive patients using anticoagulants who underwent endoscopic biopsy, mucosal resection, or submucosal dissection were prospectively enrolled across 11 hospitals. The primary outcome assessed was difference in incidence of post-procedural gastrointestinal bleeding in patients using VKAs and DOACs. Duration of hospitalization and peri-procedural thromboembolic events were also compared. Results We enrolled 174 patients using VKAs and 37 using DOACs. In total, 16 patients using VKA were excluded from the analysis because of cancellation of endoscopic procedures and contraindications to the use of DOACs; 128 (81 %) patients using VKAs and 17 (46 %) using DOACs received heparin-bridging therapy (HB). The rate of post-procedural gastrointestinal bleeding in DOAC users was similar to that in VKA users (16.2 % vs. 16.4 %, P = 1.000). Duration of hospitalization was significantly longer in patients using VKAs than in those using DOACs (median 15 vs. 7 days, P < 0.0001). Myocardial infarction occurred during pre-endoscopic HB in one patient using VKAs. Conclusion DOAC administration showed similar post-procedural gastrointestinal bleeding risk to VKA administration in patients undergoing endoscopic procedures, but it shortened the hospital stay.

scholarly journals Direct oral anticoagulants (DOAC) for prevention of recurrent arterial or venous thromboembolic events (ATE/VTE) in myeloproliferative neoplasms

2020 ◽  
Author(s):  
Karlo Huenerbein ◽  
Parvis Sadjadian ◽  
Tatjana Becker ◽  
Vera Kolatzki ◽  
Eva Deventer ◽  
...  
Keyword(s):  
Myeloproliferative Neoplasms ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Thromboembolic Events ◽  
Number Of Patients ◽  
Increased Risk ◽  
Venous Thromboembolic Events ◽  
Venous Thromboembolic

AbstractIn patients with BCR-ABL-negative myeloproliferative neoplasms (MPN), arterial or venous thromboembolic events (ATE/VTE) are a major burden. In order to control these complications, vitamin K antagonists (VKA) are widely used. There is no robust evidence supporting the use of direct oral anticoagulants (DOAC) in MPN patients. We therefore compared the efficacy and safety of both anticoagulants in 71 cases from a cohort of 782 MPN patients. Seventy-one of 782 MPN patients (9.1%) had ATE/VTE with nine ATE (12.7%) and 62 VTE (87.3%). Forty-five of 71 ATE/VTE (63.4%) were treated with VKA and 26 (36.6%) with DOAC. The duration of anticoagulation therapy (p = 0.984), the number of patients receiving additional aspirin (p = 1.0), and the proportion of patients receiving cytoreductive therapy (p = 0.807) did not differ significantly between the VKA and DOAC groups. During anticoagulation therapy, significantly more relapses occurred under VKA (n = 16) compared to DOAC treatment (n = 0, p = 0.0003). However, during the entire observation period of median 3.2 years (0.1–20.4), ATE/VTE relapse-free survival (p = 0.2) did not differ significantly between the two anticoagulants. For all bleeding events (p = 0.516) or major bleeding (p = 1.0), no significant differences were observed between VKA and DOAC. In our experience, the use of DOAC was as effective and safe as VKA, possibly even potentially beneficial with a lower number of recurrences and no increased risk for bleedings. However, further and larger studies are required before DOAC can be routinely used in MPN patients.

scholarly journals Primary Thromboprophylaxis in Patients with Malignancies: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO), the Society of Thrombosis and Hemostasis Research (GTH), and the Austrian Society of Hematology and Oncology (ÖGHO)

Cancers ◽  
2021 ◽  
Vol 13 (12) ◽  
pp. 2905
Author(s):  
Martin Kirschner ◽  
Nicole do Ó Hartmann ◽  
Stefani Parmentier ◽  
Christina Hart ◽  
Larissa Henze ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cancer Patients ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Working Party ◽  
Major Surgery ◽  
Thrombotic Risk ◽  
Indwelling Catheters ◽  
Increased Risk

Patients with cancer, both hematologic and solid malignancies, are at increased risk for thrombosis and thromboembolism. In addition to general risk factors such as immobility and major surgery, shared by non-cancer patients, cancer patients are exposed to specific thrombotic risk factors. These include, among other factors, cancer-induced hypercoagulation, and chemotherapy-mediated endothelial dysfunction as well as tumor-cell-derived microparticles. After an episode of thrombosis in a cancer patient, secondary thromboprophylaxis to prevent recurrent thromboembolism has long been established and is typically continued as long as the cancer is active or actively treated. On the other hand, primary prophylaxis, even though firmly established in hospitalized cancer patients, has only recently been studied in ambulatory patients. This recent change is mostly due to the emergence of direct oral anticoagulants (DOACs). DOACs have a shorter half-life than vitamin K antagonists (VKA), and they overcome the need for parenteral application, the latter of which is associated with low-molecular-weight heparins (LMWH) and can be difficult for the patient to endure in the long term. Here, first, we discuss the clinical trials of primary thromboprophylaxis in the population of cancer patients in general, including the use of VKA, LMWH, and DOACs, and the potential drug interactions with pre-existing medications that need to be taken into account. Second, we focus on special situations in cancer patients where primary prophylactic anticoagulation should be considered, including myeloma, major surgery, indwelling catheters, or immobilization, concomitant diseases such as renal insufficiency, liver disease, or thrombophilia, as well as situations with a high bleeding risk, particularly thrombocytopenia, and specific drugs that may require primary thromboprophylaxis. We provide a novel algorithm intended to aid specialists but also family practitioners and nurses who care for cancer patients in the decision process of primary thromboprophylaxis in the individual patient.

Major gastrointestinal bleeding risk with direct oral anticoagulants

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Dhruvil Radadiya ◽  
Kalpit Devani ◽  
Bhaumik Brahmbhatt ◽  
Chakradhar Reddy
Keyword(s):  
Gastrointestinal Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk

scholarly journals Broadening the Categories of Patients Eligible for Extended Venous Thromboembolism Treatment

2019 ◽  
Vol 120 (01) ◽  
pp. 014-026 ◽  
Author(s):  
Marc Schindewolf ◽  
Jeffrey Ian Weitz
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Venous Thromboembolism ◽  
Profile Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Specific Risk ◽  
Increased Risk

AbstractTraditionally, venous thromboembolism (VTE) resulting from major transient risk factors (e.g., surgery or trauma) or a major persistent risk factor such as cancer, has been defined as being provoked, whereas unprovoked VTE encompasses events without an identifiable cause. These categorizations influence anticoagulant treatment duration; unlike VTE provoked by major transient risk factors, extended anticoagulation beyond 3 months is advised for patients with cancer or unprovoked VTE due to risk persistence after treatment cessation. However, some patients with VTE provoked by minor transient or minor persistent risk factors may also be candidates for extended anticoagulation therapy due to the continuing risk of recurrence. In patients who require extended therapy, vitamin K antagonists (VKAs) are effective but are associated with an increased risk of bleeding and various treatment burdens (e.g., anticoagulation monitoring and dose adjustment). Evaluations of extended VTE treatment with the less-burdensome direct oral anticoagulants such as apixaban, dabigatran, edoxaban, and rivaroxaban show that they are at least as safe and effective as VKAs in a broad range of patients. In addition, apixaban and rivaroxaban offer more than one dosing option, allowing tailoring of treatment to the patient's specific risk factor profile. Analysis of more granular definitions for risk factor groupings has also yielded vital information on the most appropriate strategies for the treatment of patients with specific risk factors, highlighting that extended anticoagulation treatment may benefit those with minor transient and persistent environmental and nonenvironmental risk factors who commonly receive shorter-duration therapy.

scholarly journals Direct oral anticoagulants and digestive bleeding: therapeutic management and preventive measures

2017 ◽  
Vol 10 (6) ◽  
pp. 495-505 ◽  
Author(s):  
David Deutsch ◽  
Christian Boustière ◽  
Emile Ferrari ◽  
Pierre Albaladejo ◽  
Pierre-Emmanuel Morange ◽  
...  
Keyword(s):  
Renal Function ◽  
Gastrointestinal Bleeding ◽  
Preventive Measures ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Rapid Onset ◽  
Treatment Monitoring ◽  
Onset Of Action

The use of direct oral anticoagulants (DOACs) was an important step forward in the management of atrial fibrillation and venous thromboembolism (VTE). The DOACs, anti-IIa for dabigatran and anti-Xa for rivaroxaban, apixaban and edoxaban, all have a rapid onset of action and a short half life. There is no need for routine hemostasis testing for treatment monitoring of a DOAC. Compared with vitamin K antagonists (VKAs), DOACs may increase the risk of gastrointestinal bleeding (relative risk 1.25). Withholding the DOAC treatment, evaluating the time of the last intake and estimating the patient’s renal function are the first steps in the management of gastrointestinal bleeding. For patients without impaired renal function, achieving low coagulation takes around 24 h after the last intake of a DOAC. The use of DOAC antagonists will be helpful in controlling bleeding in the most severe and urgent situations. Idarucizumab is available for clinical use for dabigatran and andexanet is currently being reviewed by drug agencies for rivaroxaban, apixaban and edoxaban. It is important to assess the bleeding risk associated with the planned procedure, and the patient’s renal function before withholding DOAC therapy for a scheduled intervention. It is mandatory to strengthen the local hemostasis strategies in DOAC-treated patients undergoing a therapeutic endoscopic procedure. Resuming or not resuming anticoagulation with a DOAC after bleeding or a risky procedure depends on the thrombotic and bleeding risk as well as the procedure involved. This discussion should always involve the cardiologist and decisions should be taken by a pluridisciplinary team.

scholarly journals Gastrointestinal Bleeding and Direct Oral Anticoagulants among Patients with Atrial Fibrillation: Risk, Prevention, Management, and Quality of Life

TH Open ◽  
2021 ◽  
Vol 05 (02) ◽  
pp. e200-e210
Author(s):  
Paolo Zappulla ◽  
Valeria Calvi
Keyword(s):  
Quality Of Life ◽  
Gastrointestinal Bleeding ◽  
Current Knowledge ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Current Evidence ◽  
Increased Risk

AbstractA significant problem for patients undergoing oral anticoagulation therapy is gastrointestinal bleeding (GIB), a problem that has become increasingly urgent following the introduction of direct oral anticoagulants (DOACs). Furthermore, in recent years a greater focus has been placed on the quality of life (QOL) of patients on long-term oral anticoagulant therapy, which necessitates changes in lifestyle, as well as posing an increased risk of bleeding without producing objective symptomatic relief. Here, we examine current evidence linked to GIB associated with oral anticoagulants, with a focus on randomized control trials, meta-analyses, and postmarketing observational studies. Rivaroxaban and dabigatran (especially the 150-mg bis-in-die dose) appeared to be linked to an increased risk of GIB. The risk of GIB was also greater when edoxaban was used, although this was dependent on the dose. Apixaban did not pose a higher risk of GIB in comparison with warfarin. We provided a summary of current knowledge regarding GIB risk factors for individual anticoagulants, prevention strategies that lower the risk of GIB and management of DOAC therapy after a GIB episode.

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