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Cited by 222Atrial Fibrillation Management and OutcomesGastrointestinal Bleeding Diagnosis and TreatmentAntiplatelet Therapy and Cardiovascular Diseases

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Association of Oral Anticoagulants and Proton Pump Inhibitor Cotherapy With Hospitalization for Upper Gastrointestinal Tract Bleeding

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Ray, Wayne A., Chung, Cecilia P., Murray, Katherine T., Smalley, Walter E., Daugherty, James R., Dupont, William D., Stein, C. Michael·2018·JAMA
DOI 10.1001/jama.2018.17242PMC PMC6404233
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Abstract

Importance: Anticoagulant choice and proton pump inhibitor (PPI) cotherapy could affect the risk of upper gastrointestinal tract bleeding, a frequent and potentially serious complication of oral anticoagulant treatment. Objectives: To compare the incidence of hospitalization for upper gastrointestinal tract bleeding in patients using individual anticoagulants with and without PPI cotherapy, and to determine variation according to underlying gastrointestinal bleeding risk. Design, Setting, and Participants: Retrospective cohort study in Medicare beneficiaries between January 1, 2011, and September 30, 2015. Exposures: Apixaban, dabigatran, rivaroxaban, or warfarin with or without PPI cotherapy. Main Outcomes and Measures: Hospitalizations for upper gastrointestinal tract bleeding: adjusted incidence and risk difference (RD) per 10 000 person-years of anticoagulant treatment, incidence rate ratios (IRRs). Results: There were 1 643 123 patients with 1 713 183 new episodes of oral anticoagulant treatment included in the cohort (mean [SD] age, 76.4 [2.4] years, 651 427 person-years of follow-up [56.1%] were for women, and the indication was atrial fibrillation for 870 330 person-years [74.9%]). During 754 389 treatment person-years without PPI cotherapy, the adjusted incidence of hospitalization for upper gastrointestinal tract bleeding (n = 7119) was 115 per 10 000 person-years (95% CI, 112-118). The incidence for rivaroxaban (n = 1278) was 144 per 10 000 person-years (95% CI, 136-152), which was significantly greater than the incidence of hospitalizations for apixaban (n = 279; 73 per 10 000 person-years; IRR, 1.97 [95% CI, 1.73-2.25]; RD, 70.9 [95% CI, 59.1-82.7]), dabigatran (n = 629; 120 per 10 000 person-years; IRR, 1.19 [95% CI, 1.08-1.32]; RD, 23.4 [95% CI, 10.6-36.2]), and warfarin (n = 4933; 113 per 10 000 person-years; IRR, 1.27 [95% CI, 1.19-1.35]; RD, 30.4 [95% CI, 20.3-40.6]). The incidence for apixaban was significantly lower than that for dabigatran (IRR, 0.61 [95% CI, 0.52-0.70]; RD, -47.5 [95% CI,-60.6 to -34.3]) and warfarin (IRR, 0.64 [95% CI, 0.57-0.73]; RD, -40.5 [95% CI, -50.0 to -31.0]). When anticoagulant treatment with PPI cotherapy (264 447 person-years; 76 per 10 000 person-years) was compared with treatment without PPI cotherapy, risk of upper gastrointestinal tract bleeding hospitalizations (n = 2245) was lower overall (IRR, 0.66 [95% CI, 0.62-0.69]) and for apixaban (IRR, 0.66 [95% CI, 0.52-0.85]; RD, -24 [95% CI, -38 to -11]), dabigatran (IRR, 0.49 [95% CI, 0.41-0.59]; RD, -61.1 [95% CI, -74.8 to -47.4]), rivaroxaban (IRR, 0.75 [95% CI, 0.68-0.84]; RD, -35.5 [95% CI, -48.6 to -22.4]), and warfarin (IRR, 0.65 [95% CI, 0.62-0.69]; RD, -39.3 [95% CI, -44.5 to -34.2]). Conclusions and Relevance: Among patients initiating oral anticoagulant treatment, incidence of hospitalization for upper gastrointestinal tract bleeding was the highest in patients prescribed rivaroxaban, and the lowest for patients prescribed apixaban. For each anticoagulant, the incidence of hospitalization for upper gastrointestinal tract bleeding was lower among patients who were receiving PPI cotherapy. These findings may inform assessment of risks and benefits when choosing anticoagulant agents.

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Metadata

Authors
Ray, W. A., Chung, C. P., Murray, K. T., Smalley, W. E., Daugherty, J. R., Dupont, W. D., & Stein, C. M.
Affiliations
Vanderbilt University (US)
Corresponding author
Ray, Wayne A.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2018-12-04
Volume
320
Issue
21
Pages
2221
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2018.17242
PMC
PMC6404233
OpenAlex
W2903247782
Cited by
222
References
29
Citations by year
2026: 15 · 2025: 20 · 2024: 26 · 2023: 27 · 2022: 39 · 2021: 37 · 2020: 31 · 2019: 26 · 2018: 1
FWCI
17.94
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Heart, Lung, and Blood Institute (R01HL114518)
  • National Institute of Arthritis and Musculoskeletal and Skin Diseases (K23AR064768)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
  • Health Sciences › Medicine › Gastroenterology › Gastrointestinal Bleeding Diagnosis and Treatment
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
Keywords
oral anticoagulants, proton pump inhibitors, upper gastrointestinal bleeding, hospitalization, apixaban, dabigatran, rivaroxaban, warfarin, atrial fibrillation, bleeding risk, Medicare beneficiaries, risk difference, incidence rate ratio, bleeding complications, anticoagulant reversal, vitamin K antagonists, direct oral anticoagulants
MeSH terms
Rivaroxaban, Dabigatran, Administration, Oral, Aged, Aged, 80 and over, Anticoagulants, Drug Therapy, Combination, Female, Gastrointestinal Hemorrhage, Hospitalization, Humans, Male, Middle Aged, Pyrazoles, Pyridones, Retrospective Studies, Warfarin, Upper Gastrointestinal Tract, Proton Pump Inhibitors

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