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Introduction The novel oral anticoagulants (NOACs), are increasingly favoured over conventional anticoagulants given their convenience and reduced drug interactions. Although NOACs have a favourable safety profile, the innate risk of haemorrhagic complications, including upper gastrointestinal bleeding (UGIB) is still a concern in high-risk patients. In light of this, we reviewed the outcomes of UGIB in patients on NOACs in our institution and compared them to patients not receiving any anticoagulation. Methods We identified inpatients on NOACs from a prospectively collected audit of 680 consecutive gastroscopies performed in 600 patients with UGIB between 1 August 2016 to 30 November 2017. Results (NOAC patients): 42 patients (avg age 76.8 years, range 36–91, 50% female) on NOACs underwent a gastroscopy for UGIB, 32 on Apixiban and 10 on Rivaroxaban. Nine (21.4%) were co-prescribed antiplatelet agents. Most common indications for anticoagulation were atrial fibrillation (78.6%) followed by thromboembolic disease (21.4%). 12 patients (28.6%) required endotherapy, with the most commonly encountered pathology being duodenal ulceration, followed by gastric ulceration. Four patients re-bled, all of whom underwent repeat gastroscopy where definitive haemostasis was achieved. Six patients (14.3%) died within 30 days of their gastroscopy (avg age 82.2 years, range 73–88), 3 as a direct result of an UGIB. All deaths occurred in patients with multiple comorbidities. Comparison to group without anticoagulation: Patients on NOACs were older (76.8 years vs 63.9 years, p-value 0.0001), hadslightly higher rebleed rates (9.5% vs 8.3%)and had a trend to higher UGIB related 30 day mortality rate (7.1% vs 2.4%). Conclusions A portion of patients on NOACs died as a direct consequence of GI bleeding. All deaths occurred in elderly patients with multiple comorbid illnesses emphasising the importance of robust patient selection in NOAC prescription. To date Dabigatran is the only NOAC with a licenced reversal agent, Idarucizumab. Until reversal agents are available for the other NOACs perhaps Dabigatran should be preferentially considered in high risk patients despite its limitations and bleeding risk. |
