Restarting Warfarin vs Direct Oral Anticoagulants After Major Gastrointestinal Bleeding and Associated Outcomes in Atrial Fibrillation: A Cohort Study

Abstract

Limited data exist on the management of anticoagulation after hospitalization for gastrointestinal bleeding (GIB) and the risks of recurrent GIB and thromboembolism in patients who are prescribed warfarin vs direct oral anticoagulants (DOACs). The purpose of this study was to assess the risk of recurrent GIB and thromboembolism with resumption of anticoagulation after GIB. This was a retrospective analysis of adults with atrial fibrillation prescribed warfarin or DOACs and subsequently hospitalized for GIB. We used claims data from IBM MarketScan Databases from January 2008 through December 2017. Multivariable time-varying regression was used to determine the risks of recurrent GIB and thromboembolism within 6 months of the index hospitalization. There were 2991 patients hospitalized for GIB on anticoagulants (warfarin, n= 1872; rivaroxaban, n= 676; dabigatran, n= 293; and apixaban, n= 250). Of warfarin users, 46% (n= 869) resumed warfarin after discharge compared with 43% (n= 483) of DOAC users who resumed DOACs. In the regression analysis modeling time-varying coefficients for anticoagulant use, warfarin resumption was associated with an increased risk of recurrent GIB (hazard ratio [HR], 2.12; 95% CI, 1.43-3.14; P= .0002) compared with no anticoagulant resumption, whereas there was no association with DOAC resumption and recurrent bleeding (HR, 1.43; 95% CI, 0.81-2.52; P= .22). Rivaroxaban was the only individual DOAC that was associated with recurrent GIB (HR, 2.73; 95% CI, 1.43-5.20; P= .002). Both warfarin (HR, 0.61; 95% CI, 0.39-0.96; P= .033) and DOAC (HR, 0.52; 95% CI, 0.28-0.98; P= .044) resumption as a class was associated with a decreased risk of thromboembolism. Either warfarin or DOAC resumption after hospitalization for GIB was associated with a decreased risk of thromboembolism, whereas warfarin and rivaroxaban resumption were associated with an increased risk of recurrent GIB.