Can a patient with bladder diverticulum be on blood thinners, such as warfarin (anticoagulant) or novel oral anticoagulants (NOACs), like apixaban (anti-factor Xa) or rivaroxaban (anti-factor Xa)?

From the Guidelines

Patients with bladder diverticulum can generally be on blood thinners, such as warfarin or NOACs (apixaban, rivaroxaban), but this requires careful consideration of individual bleeding risk. The presence of a bladder diverticulum alone is not an absolute contraindication to anticoagulation therapy. However, if the diverticulum has a history of bleeding or shows signs of inflammation or infection, anticoagulation may need to be temporarily held or adjusted. For patients requiring anticoagulation who have bladder diverticula, regular urological monitoring is recommended to assess for hematuria or other complications.

Key Considerations

• If anticoagulation is necessary, NOACs might be preferred over warfarin in some cases due to their more predictable anticoagulant effect and potentially lower risk of bleeding complications, as seen in the 2019 AHA/ACC/HRS guideline update 1.
• The decision to use anticoagulants should be based on weighing the thrombotic risk against bleeding risk, considering factors such as the size and condition of the diverticulum, the patient's age, kidney function, and concurrent medications.
• Any signs of gross hematuria while on anticoagulants should prompt immediate medical evaluation.

Anticoagulant Options

• Warfarin: can be used, but requires regular INR monitoring 1.
• NOACs (e.g. apixaban, rivaroxaban): may be preferred due to their predictable anticoagulant effect and lower risk of bleeding complications 1.

Monitoring and Adjustments

• Regular urological monitoring is recommended to assess for hematuria or other complications.
• Anticoagulation may need to be temporarily held or adjusted if the diverticulum has a history of bleeding or shows signs of inflammation or infection.
• The NCCN guidelines version 2.2024 provide recommendations for therapeutic anticoagulation for VTE, including the use of DOACs and LMWH 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Bladder Diverticulum and Blood Thinners

• There is limited research directly addressing the use of blood thinners in patients with bladder diverticulum.
• However, studies on the use of anticoagulants in patients with other conditions, such as colonic diverticular bleeding, may provide some insight 2, 3.
• The use of warfarin and direct oral anticoagulants (DOACs) has been compared in patients with colonic diverticular bleeding, with DOACs being associated with a lower risk of stroke and/or systemic embolism, but varying risks of major bleeding 2.
• In patients with nonvalvular atrial fibrillation and a high risk of gastrointestinal bleeding, NOACs were associated with lower rates of stroke and/or systemic embolism, but had varying risks of major bleeding compared to warfarin 4.
• The risk factors for adverse in-hospital outcomes in acute colonic diverticular hemorrhage, including transfusion, further bleeding, and prolonged length of stay, have been identified, with warfarin use being an independent risk factor for transfusion need 3.
• A case study reported the successful use of rivaroxaban in a patient with a history of nephrotic syndrome and hypercoagulability, who had experienced pulmonary emboli while on warfarin 5.

Considerations for Patients with Bladder Diverticulum

• Patients with bladder diverticulum may be at risk of bleeding, particularly if they are taking anticoagulants.
• The decision to use blood thinners in patients with bladder diverticulum should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• More research is needed to determine the safety and efficacy of blood thinners in patients with bladder diverticulum.