Impact of new oral anticoagulants on gastrointestinal bleeding in atrial fibrillation: A meta-analysis of interventional trials

Background: New oral anticoagulants represent an alternative to standard therapy with vitamin K antagonists but data regarding gastrointestinal bleeding are still unclear. Aims: To investigate if new oral anticoagulants are associated with an enhanced risk of gastrointestinal bleeding vs warfarin in patients with atrial fibrillation. Methods: Meta-analysis of phase three randomized controlled trials to compare the incidence of gastrointestinal bleeding in atrial fibrillation patients treated with new oral anticoagulants (apixaban, dabigatran, edoxaban and rivaroxaban) vs warfarin. Results: Four studies including 71,302 patients were selected. Compared with warfarin, new oral anticoagulants significantly increased gastrointestinal bleeding (RR: 1.23; 95% CI 1.03-1.46; p = 0.01). Rivaroxaban (RR: 1.46; 95% CI 1.2-1.8; p <. 0.001) and high dosages of edoxaban (RR: 1.22; 95% CI 1.01-1.47; p = 0.038) and dabigatran (RR: 1.50; 95% CI 1.20-1.88; p <. 0.001) significantly increased gastrointestinal bleeding while a null effect was detected with apixaban. Conclusions: This meta-analysis suggests that rivaroxaban and high dosages of dabigatran and edoxaban should be avoided in patients at high risk of gastrointestinal bleeding.