Bleeding Risk

Which Oral Anticoagulant Confers the Lowest GI Bleeding Risk?

Treatment with apixaban conferred the lowest risk for upper gastrointestinal bleeding when compared with other oral anticoagulants, according to the results of a recent study.


Although previous observation data has suggested that certain non-vitamin K oral anticoagulants (NOACs) confer different risks of gastrointestinal bleeding, the clinical importance of anticoagulant choice, and how cotherapy with proton pump inhibitors (PPIs) affect this risk, is currently unknown.


In order to better clarify the different bleeding risks associated with various NOACs, researchers conducted a retrospective cohort study involving 1,643,123 Medicare beneficiaries with 1,713,183 new episodes of oral anticoagulant treatment.


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Over 754,389 treatment person-years without PPI cotherapy, the adjusted incidence of hospitalization for upper gastrointestinal tract bleeding was 115 per 10,000 person years. Specifically, the incidence for rivaroxaban was 144 per 10,000 person-years, which was significantly greater than the incidence for apixaban (73 per 10,000 person-years), dabigatran (120 per 10,000 person-years), and warfarin (113 per 10,000 person-years).


When comparing anticoagulant treatment with PPI cotherapy with treatment without PPI cotherapy, risk of hospitalizations for upper gastrointestinal tract bleeding was lower overall and for apixaban, dabigatran, rivaroxaban, and warfarin.


“Among patients initiating oral anticoagulant treatment, incidence of hospitalization for upper gastrointestinal tract bleeding was the highest for rivaroxaban and lowest for apixaban. For each anticoagulant, the incidence was lower among patients receiving PPI cotherapy. These findings may inform assessment of risks and benefits when choosing anticoagulant agents,” the researchers concluded.


—Michael Potts



Ray WA, Chung CP, Murray KT, et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding. JAMA. 2018;320(21):2221-2230.