From the Guidelines
Direct oral anticoagulants (DOACs) should be used with caution in patients with active peptic ulcer disease due to the increased risk of gastrointestinal bleeding, as stated in the 2024 ESC guidelines for the management of atrial fibrillation 1. While not absolute contraindications, DOACs including apixaban, rivaroxaban, edoxaban, and dabigatran can increase bleeding risk in patients with existing GI lesions. For patients with active peptic ulcers, consider delaying DOAC therapy until the ulcer has healed or opt for alternative anticoagulation with close monitoring. Some key points to consider when managing patients with peptic ulcer disease and DOACs include:
- The use of proton pump inhibitors (PPIs) to reduce GI bleeding risk, as PPIs are commonly co-prescribed with anticoagulation in clinical practice 1
- Regular monitoring for signs of GI bleeding, such as melena, hematemesis, or unexplained anemia
- Assessment of patients with active bleeding, including confirmation of the bleeding site, bleeding severity, and type/dose/timepoint of last anticoagulant intake 1
- Consideration of specific coagulation tests for DOACs, such as diluted thrombin time or chromogenic anti-factor Xa assay, to guide management 1
- The potential for reversal of anticoagulant effect with idarucizumab in patients taking dabigatran 1. It is essential to weigh the benefits and risks of DOAC therapy in patients with peptic ulcer disease, as the evidence suggests that the benefits of secondary prophylaxis outweigh the risks in high-risk patients 1.
From the Research
DOAC Contraindications and Peptic Ulcer
- The risk of gastrointestinal bleeding, including peptic ulcers, is a concern in patients taking direct oral anticoagulants (DOACs) 2, 3, 4, 5, 6.
- Studies have shown that certain DOACs, such as dabigatran and rivaroxaban, may increase the risk of gastrointestinal bleeding compared to warfarin 2.
- The use of gastroprotective agents (GPAs) may reduce the risk of upper gastrointestinal bleeding in patients taking DOACs, especially in those with a history of peptic ulcer or concomitant use of antiplatelet agents 3.
- A history of peptic ulcer or upper gastrointestinal bleeding is a significant risk factor for gastrointestinal bleeding in patients taking DOACs 3, 5.
- Concomitant use of oral bisphosphonates and DOACs may increase the risk of peptic ulcers compared to either drug alone, although the risk is abolished when excluding individuals with a previous ulcer 6.
Risk Factors for Peptic Ulcer in DOAC Users
- Age > 65 years 4, 5
- History of peptic ulcer or upper gastrointestinal bleeding 3, 5
- Concomitant use of antiplatelet agents 3
- Concomitant use of oral bisphosphonates 6
- Uncontrolled hypertension 4
- Hepatic or renal dysfunction 4
- Active cancer 4
- Anaemia 4