Anticoagulation Therapy in Patients with Gastric Ulcers

General Considerations in Patients with Gastric Ulcers

Patients with active gastric ulcers have a higher risk of gastrointestinal bleeding when receiving oral anticoagulants, according to the European Society of Gastrointestinal Endoscopy 1
The choice of anticoagulant should consider the risk of gastrointestinal bleeding, renal function, and advanced age, as recommended by the European Heart Society 2, 3
In patients with a high risk of gastrointestinal bleeding, it is recommended to consider alternatives to direct oral anticoagulants (DOACs) or choose the DOAC with the lowest risk of bleeding, as suggested by the International Society on Thrombosis and Haemostasis 4

Apixaban has the most favorable gastrointestinal safety profile among DOACs, with only 25% eliminated through the renal route, making it safer for patients with renal insufficiency, according to the American College of Cardiology 5, 3
Apixaban is associated with a lower risk of gastrointestinal bleeding compared to dabigatran and rivaroxaban, with a hazard ratio of 0.39 and 0.33, respectively, as reported by the European Society of Cardiology 6
The recommended dose of apixaban is 5 mg twice daily, with a reduction to 2.5 mg twice daily if the patient meets two of three criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥133 mmol/L, as recommended by the European Heart Society 6

In case of active bleeding, consider temporarily suspending the anticoagulant, as recommended by the American Gastroenterological Association 1
For severe bleeding, immediately interrupt the DOAC, according to the International Society on Thrombosis and Haemostasis 1
In case of potentially life-threatening bleeding, consider using specific inhibitors such as idarucizumab (for dabigatran) or andexanet (for factor Xa inhibitors), as suggested by the European Society of Gastrointestinal Endoscopy 1

First option: Apixaban at a reduced dose of 2.5 mg twice daily due to age ≥80 years and probable renal function deterioration, as recommended by the European Heart Society 6
Second option: Low molecular weight heparin if the risk of gastrointestinal bleeding is very high or if there is active bleeding, according to the International Society on Thrombosis and Haemostasis 4, 3

Closely monitor renal function, as recommended by the National Kidney Foundation 3
Evaluate potential drug interactions with other medications the patient may be taking, according to the American Society of Clinical Oncology 7
Reassess the risk-benefit balance of anticoagulation periodically, as suggested by the International Society on Thrombosis and Haemostasis 4

Endoscopic control of the gastric ulcer, as recommended by the European Society of Gastrointestinal Endoscopy 5
Monitoring of signs of gastrointestinal bleeding, according to the American Gastroenterological Association 1
Periodic evaluation of renal function, as suggested by the National Kidney Foundation 2

Dabigatrán, rivaroxabán, and edoxabán are associated with a higher incidence of gastrointestinal bleeding compared to warfarina, particularly in the lower gastrointestinal tract, with a notable increase in risk among elderly patients 8, 9, 10
The American College of Gastroenterology recommends considering the risk of gastrointestinal bleeding when selecting a DOAC, with apixaban being a preferred option for patients with active gastric ulcers or high risk of gastrointestinal bleeding 11

Patients with active gastrointestinal cancer and ulcers should not receive DOACs when alternative anticoagulants are available, due to higher rates of gastrointestinal bleeding with edoxabán and rivaroxabán 12
The European Society of Medical Oncology suggests that low molecular weight heparin (LMWH) should be considered in patients with a high risk of gastrointestinal bleeding or active bleeding, particularly in those with gastrointestinal cancer and venous thromboembolism 12

Concomitant use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) significantly increases the risk of gastrointestinal bleeding with DOACs 10
Age >65 years, excessive alcohol consumption, uncontrolled hypertension, liver or kidney dysfunction, active cancer, and anemia are additional risk factors for gastrointestinal bleeding with DOACs 10