Anticoagulants compared for associated risk of hospitalization due to upper GI bleeding

Proton-pump inhibitor cotherapy significantly reduced risk among patients on anticoagulation, a cohort study found.

Incidence of hospitalization for upper gastrointestinal (GI) bleeding after starting oral anticoagulation was highest in patients prescribed rivaroxaban, lowest for patients prescribed apixaban, and generally lower in patients who were receiving proton-pump inhibitor (PPI) cotherapy, a study found.

To compare the incidence of hospitalization for upper GI bleeding in patients using individual anticoagulants with and without PPI cotherapy, and to determine variation according to underlying GI bleeding risk, researchers conducted a retrospective cohort study from January 2011 to September 2015. They included Medicare beneficiaries taking apixaban, dabigatran, rivaroxaban, or warfarin with or without PPI cotherapy. Results were published Dec. 4 by JAMA.

The cohort included 1,643,123 patients with 1,713,183 new episodes of oral anticoagulant treatment. During 754,389 treatment person-years without PPI cotherapy, the overall adjusted incidence of hospitalization for upper GI bleeding (n=7,119) was 115 per 10,000 person-years (95% CI, 112 to 118).

The incidence for rivaroxaban (n=1,278) was 144 per 10,000 person-years (95% CI, 136 to 152), higher than apixaban (n=279; 73 per 10,000 person-years; incidence rate ratio [IRR], 1.97 [95% CI, 1.73 to 2.25]; risk difference [RD], 70.9 [95% CI, 59.1 to 82.7]), dabigatran (n=629; 120 per 10,000 person-years; IRR, 1.19 [95% CI, 1.08 to 1.32]; RD, 23.4 [95% CI, 10.6 to 36.2]), and warfarin (n=4,933; 113 per 10,000 person-years; IRR, 1.27 [95% CI, 1.19 to 1.35]; RD, 30.4 [95% CI, 20.3 to 40.6]). The authors noted that the incidence for apixaban was significantly lower than that for dabigatran (IRR, 0.61 [95% CI, 0.52 to 0.70]; RD, −47.5 [95% CI, −60.6 to −34.3]) and warfarin (IRR, 0.64 [95% CI, 0.57 to 0.73]; RD, −40.5 [95% CI, −50.0 to −31.0]).

Anticoagulant treatment with PPI cotherapy (264,447 person-years; 76 per 10,000 person-years) was associated with lower risk for hospitalization due to bleeding (n=2,245; overall IRR, 0.66; 95% CI, 0.62 to 0.69). This was also true for all anticoagulant subgroups, with the lowest IRR for dabigatran (0.49 [95% CI, 0.41 to 0.59]) and the highest for rivaroxaban (0.75 [95% CI, 0.68 to 0.84]).

The study's results may assist clinicians in considering bleeding risk when choosing anticoagulant agents, the authors wrote. They noted that the risk of hospitalization for upper GI bleeding varied markedly according to a patient's underlying GI risk. “These findings indicate the potential benefits of a gastrointestinal bleeding risk assessment before initiating anticoagulant treatment,” they concluded.