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  • Therapeutic endoscopy-related GI bleeding and thromboembolic events in patients using warfarin or direct oral anticoagulants: results from a large nationwide database analysis

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Endoscopy
Original article
Therapeutic endoscopy-related GI bleeding and thromboembolic events in patients using warfarin or direct oral anticoagulants: results from a large nationwide database analysis
  1. Naoyoshi Nagata1,
  2. Hideo Yasunaga2,
  3. Hiroki Matsui2,
  4. Kiyohide Fushimi3,
  5. Kazuhiro Watanabe1,
  6. Junichi Akiyama1,
  7. Naomi Uemura4,
  8. Ryota Niikura5
  1. 1 Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
  2. 2 Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
  3. 3 Department of Health Care Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
  4. 4 Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
  5. 5 Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
  1. Correspondence to Dr Naoyoshi Nagata, Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan; nnagata_ncgm{at}yahoo.co.jp

Abstract

Objective To compare the risks of postendoscopy outcomes associated with warfarin with direct oral anticoagulants (DOACs), taking into account heparin bridging and various types of endoscopic procedures.

Design Using the Japanese Diagnosis Procedure Combination database, we identified 16 977 patients who underwent 13 types of high-risk endoscopic procedures and took preoperative warfarin or DOACs from 2014 to 2015. One-to-one propensity score matching was performed to compare postendoscopy GI bleeding and thromboembolism between the warfarin and DOAC groups.

Results In the propensity score-matched analysis involving 5046 pairs, the warfarin group had a significantly higher proportion of GI bleeding than the DOAC group (12.0% vs 9.9%; p=0.002). No significant difference was observed in thromboembolism (5.4% vs 4.7%) or in-hospital mortality (5.4% vs 4.7%). The risks of GI bleeding and thromboembolism were greater in patients treated with warfarin plus heparin bridging or DOACs plus bridging than in patients treated with DOACs alone. Compared with percutaneous endoscopic gastrostomy, patients who underwent endoscopic submucosal dissection, endoscopic mucosal resection and haemostatic procedures including endoscopic variceal ligation or endoscopic injection sclerotherapy were at the highest risk of GI bleeding among the 13 types of endoscopic procedures, whereas those who underwent lower polypectomy endoscopic sphincterotomy or endoscopic ultrasound-guided fine needle aspiration were at moderate risk.

Conclusion The risk of postendoscopy GI bleeding was higher in warfarin than DOAC users. Heparin bridging was associated with an increased risk of bleeding and did not prevent thromboembolism. The bleeding risk varied by the type of endoscopic procedure.

  • Vitamin K antagonist (VKA)
  • novel oral anticoagulants (NOACs)
  • gastrointestinal hemorrhage
  • thromboembolism

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/gutjnl-2017-313999

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    Footnotes

    • Contributors NN designed the study; HY, HM and KF collected the data; NN, RN and HY performed the statistical analysis; and NN, KW, JA and NU prepared the draft of the manuscript. NN and HY mainly edited the revised the manuscript. All authors read and edited the manuscript and approved the submitted version of the manuscript.

    • Funding This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (grant numbers: H28-Policy-Designated-009 and H27-Policy-Strategy-011), the Japan Agency for Medical Research and Development, and Grants-in-Aid for Research from the National Center for Global Health and Medicine (29-2001). The funders played no role in the study design, data collection or analysis, decision to publish or preparation of the manuscript.

    • Competing interests None declared.

    • Ethics approval the Institutional Review Board at the University of Tokyo.

    • Provenance and peer review Not commissioned; externally peer reviewed.