Published online Mar 21, 2017. doi: 10.3748/wjg.v23.i11.1954
Peer-review started: December 14, 2016
First decision: December 28, 2016
Revised: January 18, 2017
Accepted: March 2, 2017
Article in press: March 2, 2017
Published online: March 21, 2017
Processing time: 96 Days and 7.3 Hours
Novel oral anticoagulants (NOACs), which include direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), are gaining popularity in the prevention of embolic stroke in non-valvular atrial fibrillation as well as in the prevention and treatment of venous thromboembolism. However, similar to traditional anticoagulants, NOACs have the side effects of bleeding, including gastrointestinal bleeding (GIB). Results from both randomized clinical trials and observations studies suggest that high-dose dabigatran (150 mg b.i.d), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GIB compared with warfarin. Other risk factors of NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment, Helicobacter pylori infection and a past history of GIB. Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs and in patients with renal impairment, correction of modifiable risk factors, and prescription of gastroprotective agents. Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment. In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents such as idarucizumab for dabigatran and andexanent alfa for factor Xa inhibitors, and urgent endoscopic management.
Core tip: Although effective in the prevention and treatment of thromboembolism, novel oral anticoagulants (NOACs) are still associated with bleeding complications including gastrointestinal bleeding (GIB). Physicians should exercise caution in the prescription of these drugs with careful review of the indications and appropriate dosage, as well as balancing the risks and benefits. Nonetheless, patients perceived to have an increased risk of GIB should not be precluded from taking NOACs, if they are also at a high risk of stroke. Instead, physicians should recognize the risk factors associated with NOAC-related GIB in order to undertake preventive measures to reduce the risk of GIB.