Impact of direct-acting oral anticoagulants and warfarin on postendoscopic GI bleeding and thromboembolic events in patients undergoing elective endoscopy

Published:February 29, 2020DOI:

      Background and Aims

      An increasing number of patients are undergoing GI endoscopic procedures with active prescriptions for direct oral anticoagulants (DOACs). DOACs have been associated with a higher risk of GI bleeding (GIB) compared with warfarin. Our aims were to compare the risk of postendoscopic GIB and thromboembolic (TE) events among patients on DOACs versus warfarin.


      We conducted a retrospective cohort study of patients aged 18 years or older in a large integrated health care system in Southern California, who had undergone an outpatient GI endoscopic procedure and were taking a DOAC or warfarin between January 1, 2013, and October 1, 2019. We compared bleeding and thrombosis risk in the 30 days after the endoscopic procedure between the warfarin and DOAC groups using multivariate logistic regression analysis adjusted for covariates.


      Between January 1, 2013, and October 1, 2019, we identified 6765 outpatient GI endoscopic procedures in which patients received preprocedure prescriptions for either a DOAC (1587) or warfarin (5178). Overall, there was no significant difference in postprocedure GIB (odds ratio [OR], 1.165; 95% confidence interval [CI], 0.88-1.55; P = .291) or TE (OR, 0.929; 95% CI, 0.64-1.35; P = .703) between the DOAC and warfarin groups). Subgroup analysis revealed a higher risk of GIB associated with DOAC specifically with EGD procedures (OR, 1.8; 95% CI, 1.15-2.83; P = .011).


      There was no significant difference in the overall postendoscopic risk of GIB and TE events among patients with preprocedure use of DOACs compared with patients on warfarin. There may be a higher risk of GIB in patients taking DOACs and undergoing EGD.

      Graphical abstract


      CI (confidence interval), DOAC (direct oral anticoagulant), GIB (gastrointestinal bleeding), KPSC (Kaiser Permanente Southern California), OR (odds ratio), PEG (percutaneous endoscopic gastrostomy), TE (thromboembolic)
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      Linked Article

      • Warfarin should be switched to heparin bridging for patients with high thromboembolic risk
        Gastrointestinal EndoscopyVol. 92Issue 3
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          We read with great interest the article by Tien et al.1 The authors presented some new findings indicating that direct oral anticoagulants (DOAC) did not increase the risk of postendoscopic GI bleeding and thromboembolic (TE) events when compared with warfarin, as per the data of a large integrated healthcare system. Endoscopists need to continually strike a balance between bleeding and thromboembolism in patients taking anticoagulants. Notably, this research provided evidence for endoscopists regarding anticoagulant management in the preoperative stage, especially for DOAC.
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