From the Research
Patients taking Direct Oral Anticoagulants (DOACs) do not routinely require a Proton Pump Inhibitor (PPI) unless they have specific risk factors for gastrointestinal bleeding. The decision to prescribe a PPI to a patient on DOACs should be based on individual risk factors, such as history of peptic ulcer disease or gastrointestinal bleeding, concurrent use of antiplatelet drugs, NSAIDs, corticosteroids, or age over 65 with multiple comorbidities 1. If a PPI is needed, options include omeprazole 20mg daily, pantoprazole 40mg daily, or esomeprazole 40mg daily. The rationale is that while DOACs carry a risk of gastrointestinal bleeding, this risk is generally lower than with warfarin, and PPIs can reduce gastric acid production, protecting the gastric mucosa from damage and reducing bleeding risk in vulnerable patients 2. However, unnecessary long-term PPI use should be avoided due to potential adverse effects including increased risk of infections, nutrient deficiencies, and kidney disease. A study published in 2021 found that NOACs were associated with lower risk of upper gastrointestinal bleeding and mortality compared to warfarin in patients on oral anticoagulant and PPI co-therapy 1. Another study published in 2019 found that routine use of proton pump inhibitors in patients receiving low-dose anticoagulation and/or aspirin for stable cardiovascular disease does not reduce upper gastrointestinal events, but may reduce bleeding from gastroduodenal lesions 2. Key points to consider when deciding whether to prescribe a PPI to a patient on DOACs include:
- History of peptic ulcer disease or gastrointestinal bleeding
- Concurrent use of antiplatelet drugs, NSAIDs, corticosteroids
- Age over 65 with multiple comorbidities
- Potential adverse effects of long-term PPI use. It is essential to weigh the benefits and risks of PPI therapy in each patient and consider alternative strategies to reduce gastrointestinal bleeding risk, such as using a different anticoagulant or adding an antiplatelet agent 3, 4, 5.