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Martens KL, Dekker SE, Crowe M, DeLoughery TG, Shatzel JJ. Challenging clinical scenarios for therapeutic anticoagulation: A practical approach. Thromb Res 2022; 218:72-82. [PMID: 36027629 PMCID: PMC9481720 DOI: 10.1016/j.thromres.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/20/2022] [Accepted: 08/15/2022] [Indexed: 01/03/2023]
Abstract
Therapeutic anticoagulation remains a fundamental backbone in the treatment and prevention of venous thromboembolism. However, while modern therapies are increasingly safe, anticoagulation is not without risks, particularly in those at high risk for or with recent bleeding. When weighing concurrent risks and benefits in each challenging clinical scenario, an individualized assessment of the risk and acuity of bleeding should be balanced by the indication for anticoagulation. Addressing modifiable risk factors and routine re-evaluation of any changes in this balance is critical. This review outlines available data and current guidelines for the management of anticoagulation in high-risk populations, including those with thrombocytopenia, elderly and high-fall risk, inherited bleeding disorders, and in acute coronary syndrome. We also examine management after clinically significant bleeding episodes, including intracranial hemorrhage, gastrointestinal bleeding, hemoptysis, retroperitoneal bleeding, hematuria, and abnormal uterine bleeding. The aim is to provide a comprehensive review of available literature to guide clinicians in providing optimal, safe, and individualized care for patients in these challenging scenarios.
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Affiliation(s)
- Kylee L. Martens
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America,Corresponding author at: OHSU Knight Cancer Institute, 3181 SW Sam Jackson Park Road, Mail Code: OC14HO, Portland, OR 97239, United States of America. (K.L. Martens)
| | - Simone E. Dekker
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Megan Crowe
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Thomas G. DeLoughery
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America
| | - Joseph J. Shatzel
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America
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2
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Intestinal Tuberculosis Presenting with Gastrointestinal Bleeding in Patient on Warfarin Therapy. Case Rep Gastrointest Med 2022; 2022:9277789. [PMID: 35607387 PMCID: PMC9124143 DOI: 10.1155/2022/9277789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Intestinal tuberculosis (ITB) constitutes less than 5% of overall cases of extrapulmonary disease and mostly affects the ileocecal region. The presentation and radiologic findings in enteric tuberculosis can mimic Crohn's disease (CD). Case Presentation. We present a case report of an African woman who presented to a Kenyan hospital with lower gastrointestinal bleeding while on anticoagulation for valvular atrial fibrillation, and was diagnosed with intestinal tuberculosis after colonoscopy, biopsy, and positive staining for tuberculous bacilli. Conclusion Intestinal tuberculosis causing gastrointestinal bleeding is rare but should be suspected in patients living in TB endemic regions.
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3
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Jain H, Singh G, Kaul V, Gambhir HS. Management dilemmas in restarting anticoagulation after gastrointestinal bleeding. Proc (Bayl Univ Med Cent) 2022; 35:322-327. [DOI: 10.1080/08998280.2022.2043707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hanish Jain
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Garima Singh
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Viren Kaul
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Harvir Singh Gambhir
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
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4
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Little DHW, Sutradhar R, Cerasuolo JO, Perez R, Douketis J, Holbrook A, Paterson JM, Gomes T, Siegal DM. Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding. CMAJ 2021; 193:E304-E309. [PMID: 33649169 PMCID: PMC8034308 DOI: 10.1503/cmaj.201433] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND: Data on resuming oral anticoagulants (OACs) after bleeding are primarily from studies involving patients given warfarin, with few data on direct OACs (DOACs). We aimed to characterize prescribing patterns for OACs after OAC-related bleeding and compare the rates of bleeding, thrombosis and mortality in patients who resumed either type of OAC with those who did not. METHODS: We conducted a population-based cohort study of adults aged 66 years or older who were admitted to hospital for bleeding while receiving OACs from Apr. 1, 2012, to Mar. 31, 2017, using linked administrative health databases from Ontario. We used competing risk methods to calculate cause-specific adjusted hazard ratios (HRs) for thrombosis, bleeding and mortality with resumption of OACs adjusted as a time-varying covariate. We determined time to OAC resumption using the Kaplan–Meier method. RESULTS: We included 6793 patients with gastrointestinal (n = 4297, 63.3%), intracranial (n = 805, 11.9%) or other bleeding (n = 1691, 25.0%). At cohort entry, 3874 patients (57.0%) were prescribed warfarin and 2919 patients (43.0%) were prescribed a DOAC. The most common indication for OAC was atrial fibrillation (n = 5557, 81.8%), followed by venous thromboembolism (n = 1367, 20.1%). Oral anticoagulants were resumed in 4792 patients (70.5%) within 365 days of the index bleed. The median time to resumption was 46 (interquartile range 6–550) days. We found that resuming OAC was associated with reduced rates of thrombosis (adjusted HR 0.60, 95% confidence interval [CI] 0.50–0.72) and mortality (adjusted HR 0.54, 95% CI 0.48–0.60), and an increased rate of rebleeding (adjusted HR 1.88, 95% CI 1.64–2.17). INTERPRETATION: We found that resuming OAC is associated with a reduction in thrombosis and mortality but an increase in bleeding. Randomized controlled trials that evaluate the net benefit of strategies for resumption of OAC after a bleeding event are warranted.
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Affiliation(s)
- Derek H W Little
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Rinku Sutradhar
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Joshua O Cerasuolo
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Richard Perez
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - James Douketis
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Anne Holbrook
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - J Michael Paterson
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Tara Gomes
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Deborah M Siegal
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont.
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Bhandari P, Longcroft-Wheaton G, Libanio D, Pimentel-Nunes P, Albeniz E, Pioche M, Sidhu R, Spada C, Anderloni A, Repici A, Haidry R, Barthet M, Neumann H, Antonelli G, Testoni A, Ponchon T, Siersema PD, Fuccio L, Hassan C, Dinis-Ribeiro M. Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update. Endoscopy 2021; 53:535-554. [PMID: 33822332 DOI: 10.1055/a-1397-3005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities. METHODS As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined). RESULTS The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition. CONCLUSIONS Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.
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Affiliation(s)
- Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospital NHS Trust, Portsmouth, UK
| | | | - Diogo Libanio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
| | - Eduardo Albeniz
- Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Navarrabiomed-UPNA-IdiSNA, Pamplona, Spain
| | - Mathieu Pioche
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Reena Sidhu
- Academic Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Cristiano Spada
- Digestive Endoscopy and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, Rome, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Digestive Endoscopy Unit, IRCSS Humanitas Research Hospital, Milan, Italy
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany.,GastroZentrum Lippe, Bad Salzuflen, Germany
| | - Giulio Antonelli
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, Rome, Italy.,Nuovo Regina Margherita Hospital, Rome, Italy.,Department of Translational and Precision Medicine, "Sapienza" University of Rome, Rome, Italy
| | | | - Thierry Ponchon
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Mario Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
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6
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Tapaskar N, Pang A, Werner DA, Sengupta N. Resuming Anticoagulation Following Hospitalization for Gastrointestinal Bleeding Is Associated with Reduced Thromboembolic Events and Improved Mortality: Results from a Systematic Review and Meta-Analysis. Dig Dis Sci 2021; 66:554-566. [PMID: 32279174 DOI: 10.1007/s10620-020-06248-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Systemic anticoagulants are widely prescribed for prevention and treatment of thromboembolism, but are commonly complicated by gastrointestinal bleeding (GIB). Limited data exist on the management of anticoagulation after hospitalization for GIB and the subsequent risks of recurrent GIB, thromboembolism, and mortality. METHODS We performed a systematic review and meta-analysis of studies to determine risk of recurrent GIB, thromboembolism, and mortality after resuming anticoagulation following GIB. PubMed, EMBASE, and Scopus were searched for randomized controlled trials and cohort studies in patients with atrial fibrillation, venous thromboembolism, or valvular heart disease who received long-term warfarin or direct oral anticoagulants before experiencing GIB. Studies were included if data were available on anticoagulation management and outcomes of recurrent GIB, thromboembolism, and mortality following GIB. RESULTS A total of 5354 studies were reviewed of which 10 were included in the meta-analysis. There were 2080 patients who resumed anticoagulation and 2296 patients who discontinued anticoagulation post-index GIB. Resumption of anticoagulation was associated with a significant increase in recurrent GIB (OR 1.646, 95% CI 1.035-2.617, p = 0.035). There was a significant decrease in thromboembolic events in patients who resumed anticoagulation compared to those who did not (OR 0.340, 95% CI 0.178-0.652, p = 0.001, I2 = 62.7%). Resumption of anticoagulation was associated with a significant reduction in all-cause mortality (OR 0.499, 95% CI 0.419-0.595, p < 0.0001). CONCLUSION While resumption of anticoagulation following index GIB was associated with a significant increase in recurrent GIB, it was also associated with a significant decrease in thromboembolic events and all-cause mortality.
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Affiliation(s)
- Natalie Tapaskar
- Department of Medicine, University of Chicago Medicine, Chicago, USA
| | - Alice Pang
- Department of Medicine, New York University Langone Health, 550 First Avenue, New York, NY, 10022, USA
| | - Debra A Werner
- The John Crerar Library, University of Chicago, 5730 S Ellis Ave, Chicago, IL, 60637, USA
| | - Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, 5841 S Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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Patel P, Nigam N, Sengupta N. Lower gastrointestinal bleeding in patients with coronary artery disease on antithrombotics and subsequent mortality risk. J Gastroenterol Hepatol 2018; 33:1185-1191. [PMID: 29156506 DOI: 10.1111/jgh.14048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common complication for patients with coronary artery disease (CAD) due to the use of antithrombotic medications. Limited data exist describing which patients are at increased risk for mortality. AIM This study aims to (i) determine whether patients on dual antiplatelet therapy (DAPT) or triple therapy are at higher risk of 90-day and 6-month mortality compared with patients on aspirin alone and (ii) evaluate risk factors for mortality in patients with CAD on antithrombotics hospitalized with LGIB. METHODS We conducted a retrospective cohort study of patients hospitalized with LGIB and CAD while on aspirin at a single academic medical center from 2007 to 2015. Patients were identified using a validated, machine-learning algorithm and classified by use of aspirin, DAPT, or triple therapy. Univariate and multivariate Cox proportional hazards were used to determine mortality associated risk factors. RESULTS Seven hundred sixteen patients were identified with LGIB and CAD. Four hundred seventy-two (65.9%) patients were on aspirin monotherapy, 179 (25%) on aspirin and thienopyridine (DAPT), and 65 (9.1%) on aspirin, thienopyridine, and systemic anticoagulant (triple therapy). On univariate analysis, triple therapy use was associated with increased risk of 90-day (hazard ratio [HR] 3.12, 95% confidence interval [CI] 1.52-5.92, P = 0.003) and 6-month (HR 2.46, 95%CI 1.29-4.35, P = 0.008) mortality. Holding anticoagulation was associated with higher mortality at 90 days (HR 2.30, 95%CI 1.27-4.07, P = 0.007). On multivariate analysis, after adjusting for confounding variables, the use of triple therapy remained associated with higher 90-day mortality (HR 3.23, 95%CI 1.56-6.16, P = 0.003). CONCLUSION Triple therapy is associated with mortality at 90 days and at 6 months post discharge.
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Affiliation(s)
- Parita Patel
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Neha Nigam
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, Illinois, USA
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8
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Kido K, Scalese MJ. Management of Oral Anticoagulation Therapy After Gastrointestinal Bleeding: Whether to, When to, and How to Restart an Anticoagulation Therapy. Ann Pharmacother 2017. [PMID: 28639882 DOI: 10.1177/1060028017717019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate current clinical evidence for management of oral anticoagulation therapy after gastrointestinal bleeding (GIB) with an emphasis on whether to, when to, and how to resume an anticoagulation therapy. DATA SOURCES Relevant articles from MEDLINE, Cochrane Library, and EMBASE databases were identified from 1946 through May 20, 2017, using the keywords: gastrointestinal hemorrhage or gastrointestinal bleeding and antithrombotic therapy or anticoagulation therapy or warfarin or dabigatran or rivaroxaban or apixaban or edoxaban. STUDY SELECTION AND DATA EXTRACTION All English-language studies assessing management of oral anticoagulation therapy after GIB were evaluated. DATA SYNTHESIS A total of 9 studies were identified. Four retrospective cohort studies showed that resuming anticoagulation therapy was associated with significantly lower rate of thromboembolism (TE) in the general population. Meta-analyses and prospective cohort studies also supported this finding. Two retrospective cohort studies indicated an increase in GIB when anticoagulation reinitiation occurred in less than 7 days without a decrease in TE. Resuming therapy between 7 and 15 days did not demonstrate a significant increase in GIB or TE. A large retrospective study showed that apixaban was associated with the significantly lowest risk of GIB compared with both rivaroxaban and dabigatran. CONCLUSION Anticoagulation therapy resumption is recommended, with resumption being considered between 7 and 14 days following GIB regardless of the therapy chosen. Data for warfarin management after GIB should be applied with caution to direct oral anticoagulants (DOACs) because of the quicker onset and experimental nature of reversal agents. Apixaban may be a preferred option when restarting a DOAC therapy.
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Affiliation(s)
- Kazuhiko Kido
- 1 South Dakota State University, Sioux Falls, SD, USA
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