Gastrointestinal bleeding with the use of new oral anticoagulants: epidemiology, risk factors, treatment, and prevention

Novel oral anticoagulants (NOACs), such as the direct thrombin inhibitor dabigatran and the selective factor Xa inhibitors rivaroxaban and apixaban, are increasingly used as an effective antithrombotic drug in real clinical practice. Unfortunately, these medications can cause severe adverse events, including gastrointestinal bleeding, one of the most common events. This complication annually develops in 2-3% of patients taking NOACs. The sources of bleeding can be in both the upper or lower gastrointestinal tract (GIT). The common cause of bleeding is undiagnosed GIT neoplasms, often colorectal cancer. Clinical and cohort studies show that the greatest risk of bleeding is observed with the use of rivaroxaban. The risk factors are advanced age, concurrent administration of nonsteroidal anti-inflammatory drugs, aspirin, and other anticoagulants, gastrointestinal diseases, H. pylori infection, impaired renal and hepatic functions, and alcohol intake. Gastrointestinal bleeding is treated on general principles, by applying endoscopic and surgical techniques. Particular importance is attached to the blockade of the anticoagulant effects of NOACs. For this, the entire range of antidotes, such as idarucizumab (it has been already applied in several countries of the world), andex-anet, and ciraparantag, has been recently designed and is undergoing clinical trials. Bleeding prevention involves control of risk factors, rational use of NOACs, prophylactic administration of proton pump inhibitors, timely discontinuation of anticoagulation prior to traumatic medical procedures on the gastrointestinal organs (before certain endoscopic procedures in particular).