title: Gastrointestinal Safety of Direct Oral Anticoagulants: A Large Population-Based Study.
abstract: Direct oral anticoagulant (DOAC) agents increase the risk of gastrointestinal (GI) bleeding. We investigated which DOAC had the most favorable GI safety profile and compared differences among these drugs in age-related risk of GI bleeding.
  
  
  
  We conducted a retrospective, propensity-matched study using administrative claims data from the OptumLabs Data Warehouse of privately insured individuals and Medicare Advantage enrollees. We created 3 propensity-matched cohorts of patients with non-valvular atrial fibrillation with incident exposure to dabigatran, rivaroxaban, or apixaban from October 1, 2010 through February 28, 2015. We compared data on rivaroxaban vs dabigatran for 31,574 patients, data on apixaban vs dabigatran for 13,084 patients, and data on apixaban vs rivaroxaban for 13,130 patients. Cox proportional hazards models, stratified by age, were used to estimate rates of total GI bleeding.
  
  
  
  Baseline characteristics were well balanced among sub-cohorts. GI bleeding occurred more frequently in patients given rivaroxaban than dabigatran (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.00-1.45). Apixaban was associated with a lower risk of GI bleeding than dabigatran (HR, 0.39; 95% CI, 0.27-0.58; P < .001) or rivaroxaban (HR, 0.33; 95% CI, 0.22-0.49; P < .001). Rates of events for all DOACs increased among patients 75 years or older. Apixaban had a lower risk of association with GI bleeding in the very elderly than dabigatran (HR, 0.45; 95% CI, 0.29-0.71) or rivaroxaban (HR, 0.39; 95% CI, 0.25-0.61). Median times to GI bleeding were <90 days for apixaban and rivaroxaban and <120 days for dabigatran.
  
  
  
  In a population-based study of patients receiving DOAC agents, we found apixaban had the most favorable GI safety profile and rivaroxaban the least favorable profile. GI bleeding events among patient aged 75 years or older taking DOACs increased with age; the risk was greatest among persons 75 years. Apixaban had the most favorable GI safety profile among all age groups.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota. Electronic address: abraham.neena@mayo.edu.
authors.forename: Neena S
authors.initials: NS
authors.lastname: Abraham
authors.affiliation: Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Noseworthy
authors.affiliation: Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
authors.forename: Xiaoxi
authors.initials: X
authors.lastname: Yao
authors.affiliation: Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
authors.forename: Lindsey R
authors.initials: LR
authors.lastname: Sangaralingham
authors.affiliation: Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota; Optum Labs, Cambridge, Massachusetts.
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000991:Antithrombins / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D015331:Cohort Studies; D000069604:Dabigatran / Q000009:adverse effects; D065427:Factor Xa Inhibitors / Q000009:adverse effects*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced*; D006801:Humans; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D016016:Proportional Hazards Models; D011720:Pyrazoles / Q000009:adverse effects; D011728:Pyridones / Q000009:adverse effects; D012189:Retrospective Studies; D000069552:Rivaroxaban / Q000009:adverse effects; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D055815:Young Adult
chemical_list: D000991:Antithrombins; D065427:Factor Xa Inhibitors; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: Anticoagulant; Atrial Fibrillation; Comparative Safety; Gastrointestinal Hemorrhage