Effect of direct oral anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection

• Published in: Digestive endoscopy Vol. 29; no. 6; pp. 686 - 694
• Main Authors: Yoshio, Toshiyuki, Tomida, Hideomi, Iwasaki, Ryuichiro, Horiuchi, Yusuke, Omae, Masami, Ishiyama, Akiyoshi, Hirasawa, Toshiaki, Yamamoto, Yorimasa, Tsuchida, Tomohiro, Fujisaki, Junko, Yamada, Takuya, Mita, Eiji, Ninomiya, Tomoyuki, Michitaka, Kojiro, Igarashi, Masahiro
• Format: Journal Article
• Language: English
• Published: Australia 01.09.2017
• Subjects: Administration, Oral; Aged; Anticoagulants - administration & dosage; Anticoagulants - adverse effects; Antithrombins - administration & dosage; Antithrombins - adverse effects; antithrombotic therapy; Blood Transfusion - methods; Cohort Studies; Dabigatran - administration & dosage; Dabigatran - adverse effects; delayed bleeding; direct oral anticoagulant; Endoscopic Mucosal Resection - adverse effects; Endoscopic Mucosal Resection - methods; endoscopic submucosal dissection; Female; Follow-Up Studies; heparin bridge therapy; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Postoperative Hemorrhage - chemically induced; Postoperative Hemorrhage - physiopathology; Postoperative Hemorrhage - therapy; Retrospective Studies; Risk Factors; Rivaroxaban - administration & dosage; Rivaroxaban - adverse effects; Statistics, Nonparametric; Stomach Neoplasms - pathology; Stomach Neoplasms - surgery; Thromboembolism - prevention & control; Treatment Outcome; Warfarin - administration & dosage; Warfarin - adverse effects; endoscopic submucosal dissection; heparin bridge therapy; antithrombotic therapy; delayed bleeding; direct oral anticoagulant
• ISSN: 0915-5635; 1443-1661
• DOI: 10.1111/den.12859

Background and Aim Anticoagulants are used to prevent thromboembolic events. Direct oral anticoagulants (DOAC) are our new choice; however, their effect on bleeding risk for endoscopic treatment has not been reported. We aimed to assess the clinical effect of DOAC compared to warfarin for gastric endoscopic submucosal dissection (ESD). Methods We retrospectively studied 97 patients on anticoagulants and treated 108 gastric neoplasms with ESD in three referral institutes. Twenty‐four patients were taking DOAC, including dabigatran (12), rivaroxaban (11), and apixaban (one) and 73 were taking warfarin. Results In the DOAC group, delayed bleeding rate was significantly higher in patients on rivaroxaban than in patients on dabigatran (45% vs 0%, P < 0.05) without relation to heparin bridge therapy (HBT). In the warfarin group, 78% of patients underwent HBT, and delayed bleeding rate was significantly higher in patients with HBT than in those without (36% vs 0%, P < 0.05). Delayed bleeding rate increased as intake of antithrombotic agents increased (P < 0.05). HBT period was shorter (P < 0.05) in DOAC because DOAC achieve the maximum effect quicker, and hospitalization period was shorter (P < 0.05), compared with warfarin. Multivariate analysis showed that HBT (OR, 10.7), rivaroxaban (OR, 6.00) and multiple antithrombotic agents (OR, 4.35) were independent delayed bleeding risk factors. Conclusions The DOAC effect differs in each agent. Dabigatran is a feasible alternative to warfarin for shortening the hospitalization period and decreasing delayed bleeding rate, although rivaroxaban has a significantly higher delayed bleeding risk.