Restarting anticoagulant or antiplatelet treatment following a gastrointestinal bleed comes with a tradeoff. Though resumption of therapy is associated with a reduced risk for vascular events and death, the risk of rebleeding was greater, according to results from a study published in Alimentary Pharmacology and Therapeutics. The benefits of reduced risk for vascular events and death, however, seem to outweigh the increased risk of gastrointestinal events.
Researchers conducted an observational, long-term cohort study on 871 patients from 2 general hospitals in Spain. Patients were using an anticoagulant or antiplatelet and were an average of 78.9 years old. They required hospitalization due to upper (38.7%), lower (46.7%), or obscure (14.6%) gastrointestinal bleeding between January 2008 and December 2013. Prospective collection of drug use information occurred during bleeding events.
Over half of all patients (52.5%) used an antiplatelet, 38.9% used an anticoagulant, and 8.6% used both an antiplatelet and an anticoagulant. After gastrointestinal bleeding, 93.1% of patients interrupted therapy, with the majority of patients (80.5%) reinitiating therapy within 7.6 days.
With a median follow-up of 24.9 months, restarting antiplatelet or anticoagulant therapy was associated with increased risk for gastrointestinal rebleeding (hazard ratio [HR], 2.184; 95% CI, 1.357‐3.515) but, importantly, decreased risk for ischemic events (HR, 0.626; 95% CI, 0.432‐0.906) or death (HR, 0.606; 95% CI, 0.453‐0.804). Restarting therapy was associated with a similar risk for upper and lower gastrointestinal events compared with not restarting therapy.
Reinitiation of antiplatelet or anticoagulant therapy 7 days or fewer after the bleeding event was associated with a lower rate of ischemic events (13.6%) compared with reinitiating therapy more than 7 days after the event (20.4%; P =.025) but a higher rate of gastrointestinal bleeding (30.6% vs 23.1%; P =.044). There was no difference in death rates between early and late reinitiation.
Patients on anticoagulant therapy experienced higher rates of rebleeding events, at 138.0 events per 1000 patient years, compared with patients on antiplatelet therapy, at 99.0 events per 1000 patient years.
The researchers suggested that the development of risk scores and tools could support clinicians in making decisions about reinitiation of antiplatelet and anticoagulant therapy.
1. Sostres C, Marcén B, Laredo V, et al. Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmacol Ther. doi:10.1111/apt.15441