NOACs a better combo for PPIs than warfarin for reducing gastrointestinal bleeding risk

In patients on proton pump inhibitor (PPI) medication, co-treatment with nonvitamin K antagonist oral anticoagulants (NOACs), rather than warfarin, may be better and lead to lower risks of upper gastrointestinal bleeding and mortality, a recent study has found.

Drawing from the Korean National Health Insurance Service claims database, the researchers retrieved the data of 19,851 patients on anticoagulation and PPI co-therapy. The primary endpoint was major upper gastrointestinal bleeding, defined as hospitalization with red blood cell transfusion due to bleeding related to gastric, duodenal, or gastrojejunal ulcers, or haemorrhagic gastritis. Death was a secondary endpoint.

Of the participants, 35.2 percent (n=6,995) were taking warfarin as their oral anticoagulant, while the remaining ones were on the following NOACs: rivaroxaban (32.6 percent; n=6,468), dabigatran (11.6 percent; n=2,301), apixaban (13.2 percent; n=2,613), and edoxaban (7.4 percent; n=1,474).

Over a mean follow-up of 1.41±1.35 years, 512 participants were hospitalized due to major upper gastrointestinal bleeding, resulting in an incidence rate of 2.58 percent. Patients on warfarin showed a significantly higher cumulative rate of the primary outcome than comparators on NOACs (log-rank p=0.024).

After adjusting for age, sex, comorbidities, and other concomitant medications, patients on NOACs saw a 22-percent lower risk of major upper gastrointestinal bleeding than those on warfarin (hazard ratio [HR], 0.78, 95 percent confidence interval [CI], 0.65–0.94; p=0.007). Apixaban and edoxaban had the strongest effects.

Similarly, compared with warfarin, NOACs led to a small but significant drop in the likelihood of death after adjusting for confounders (HR, 0.91, 95 percent CI, 0.83–0.98; p=0.02).