Direct-acting oral anticoagulants (DOACs) are increasingly used these days. Studies suggesting that they have a lower risk of gastrointestinal bleeding (GIB). However, the risk remains debatable overall. Randomized control studies that compared warfarin and DOACs with various indications (atrial fibrillation, thromboembolism, mechanical valve insertion) were included. The primary endpoint of the study is the occurrence of any GIB event. The following are assessed:
Effects of age (≤60 years or older),
Time in the therapeutic range for warfarin,
Choice of individual DOACs on GIB risk.
87,407 participants were included in 14 RCTs (DOACs n=46,223, warfarin control n=41,184). The GIB risk was similar to warfarin and DOACs. Rivaroxaban and dabigatran (RR 1.23, 95%CI 1.03-1.48), (RR 1.38, 95%CI 1.12-1.71) had a higher risk of any GIB compared with warfarin. Fatal GIB risk was lower in the DOACs group (RR 0.36, 95%CI 0.15-0.82). DOAC-related fatal GIB was less likely to occur in patients with poor coagulation control (RR 0.39, 95%CI 0.15-0.98) and those over 60 years of age.
In contrast to warfarin, DOACs reduce the risk of fatal GIB, particularly for the elderly and those with poor coagulation control. Warfarin and DOACs were comparable to GIB risk, excluding dabigatran and rivaroxaban.