title: Gastrointestinal bleeding in patients on novel oral anticoagulants: Risk, prevention and management.
abstract: Novel oral anticoagulants (NOACs), which include direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), are gaining popularity in the prevention of embolic stroke in non-valvular atrial fibrillation as well as in the prevention and treatment of venous thromboembolism. However, similar to traditional anticoagulants, NOACs have the side effects of bleeding, including gastrointestinal bleeding (GIB). Results from both randomized clinical trials and observations studies suggest that high-dose dabigatran (150 mg b.i.d), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GIB compared with warfarin. Other risk factors of NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment,Helicobacter pyloriinfection and a past history of GIB. Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs and in patients with renal impairment, correction of modifiable risk factors, and prescription of gastroprotective agents. Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment. In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents such as idarucizumab for dabigatran and andexanent alfa for factor Xa inhibitors, and urgent endoscopic management.
authors.affiliation: Ka-Shing Cheung, Wai K Leung, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
authors.forename: Ka-Shing
authors.initials: KS
authors.lastname: Cheung
authors.affiliation: Ka-Shing Cheung, Wai K Leung, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
authors.forename: Wai K
authors.initials: WK
authors.lastname: Leung
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000517:prevention & control*; D001779:Blood Coagulation Factors / Q000819:agonists / Q000037:antagonists & inhibitors; D002986:Clinical Trials as Topic; D016099:Endoscopy, Gastrointestinal; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000517:prevention & control / Q000628:therapy*; D016481:Helicobacter Infections / Q000150:complications; D006801:Humans; D010437:Peptic Ulcer / Q000139:chemically induced / Q000150:complications; D012307:Risk Factors; D020521:Stroke / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors
keywords: Apixaban; Dabigatran; Edoxaban; Endoscopy; Gastrointestinal bleeding; Novel anticoagulants; Rivaroxaban; Warfarin