title: Management of gastrointestinal bleeding in patients anticoagulated with dabigatran compared with warfarin: a retrospective, comparative case review.
abstract: BACKGROUND
  Dabigatran etexilate, was found to be effective for stroke prevention in patients with non-valvular atrial fibrillation. Given its predictable pharmacodynamics, laboratory monitoring is not required. Moreover, the risks of overall bleeding, intracranial bleeding, and life-threatening hemorrhage from dabigatran were found to be lower than warfarin. However, a higher risk of gastrointestinal (GI) bleeding caused by dabigatran from the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial has raised the concern regarding clinical outcomes of patients with GI bleeding caused by dabigatran compared with warfarin.
  
  
  METHODS
  We retrospectively studied patients who were hospitalized for GI bleeding from dabigatran compared with warfarin with therapeutic anticoagulation monitoring during 2009 to 2012. Initial laboratory findings at presentation, number of transfused packed red blood cells (PRBCs), acute kidney injury, clinical outcomes (e.g., hypotension, tachycardia), length of stay, and death were compared.
  
  
  RESULTS
  Thirteen patients taking dabigatran and 26 patients who were on warfarin with therapeutic international normalized ratio (INR) were hospitalized during the study period. Demographic data and baseline parameters between the two groups were not significantly different except for concurrent aspirin use (84.6% vs. 50%, P=0.036). Fifty-four percent of patients taking dabigatran did not have activated partial thromboplastin time (aPTT) level performed at presentation (7/13). The patients with GI bleeding from warfarin received significantly more PRBC transfusions compared with the dabigatran group (1.92±2.2 vs. 0.69±1.1 units, P=0.024). After controlling for initial hemoglobin and history of chronic kidney disease by using multivariate analysis, the patients in the warfarin group were likely to receive more PRBC. Hypotension at presentation was more common in GI bleeding caused by warfarin than dabigatran but the P value was insignificant (30.8% vs. 7.7%, P=0.11). Nevertheless, no differences in clinical outcomes or length of stay were found between the two groups.
  
  
  CONCLUSIONS
  From our data, the patients with GI bleeding from dabigatran were likely to receive fewer PRBC transfusions; however, clinical outcomes and length of stay were comparable to GI bleeding caused by warfarin. Our sample generalizes to an elderly population (mean age of 77.9±10 years old) with creatinine clearance (CrCl) >30 mL/min who experience GI bleeding during chronic anticoagulation.
authors.affiliation: 1 Department of Internal Medicine, 2 Department of Cardiology, St John Hospital and Medical Center Detroit, Michigan, USA ; 3 Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA.
authors.forename: Wuttiporn
authors.initials: W
authors.lastname: Manatsathit
authors.affiliation: 1 Department of Internal Medicine, 2 Department of Cardiology, St John Hospital and Medical Center Detroit, Michigan, USA ; 3 Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA.
authors.forename: Hussein
authors.initials: H
authors.lastname: Al-Hamid
authors.affiliation: 1 Department of Internal Medicine, 2 Department of Cardiology, St John Hospital and Medical Center Detroit, Michigan, USA ; 3 Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA.
authors.forename: Pornchai
authors.initials: P
authors.lastname: Leelasinjaroen
authors.affiliation: 1 Department of Internal Medicine, 2 Department of Cardiology, St John Hospital and Medical Center Detroit, Michigan, USA ; 3 Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA.
authors.forename: Usman
authors.initials: U
authors.lastname: Hashmi
authors.affiliation: 1 Department of Internal Medicine, 2 Department of Cardiology, St John Hospital and Medical Center Detroit, Michigan, USA ; 3 Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: McCullough
keywords: Dabigatran; direct thrombin inhibitor; gastrointestinal bleeding (GI bleeding); warfarin