Timing of Direct Oral Anticoagulant Resumption After Outpatient Colonoscopy and Risk of Gastrointestinal Bleeding and Thromboembolic Events.

BACKGROUND & AIMS: There is limited direct evidence for when to restart direct oral anticoagulants (DOACs) after colonoscopy. Therefore, we evaluated the risks of post-colonoscopy gastrointestinal (GI) bleeding and thromboembolic events according to the timing of DOAC resumption.

METHODS

We identified 7798 Kaiser Permanente Northern California members aged ≥18 years who underwent outpatient colonoscopy between 2013 and 2022 while prescribed dabigatran, rivaroxaban, or apixaban and had documented instructions regarding DOAC resumption. Patients were categorized as early (<2 days) or delayed (≥2 days) resumption. Inverse probability of treatment weighting was used to estimate adjusted risks of GI bleeding and thromboembolic events within 30 days of colonoscopy. GI bleeding was defined as bleeding requiring emergency department evaluation or hospitalization.

RESULTS

The absolute risk of GI bleeding was modestly higher with delayed vs early DOAC resumption (2.1% vs 1.4%), as was the absolute risk of thromboembolic events (0.9% vs 0.6%). In adjusted analyses, delayed DOAC resumption was not associated with a statistically significant difference in overall GI bleeding (adjusted relative risk [aRR], 0.80; 95% confidence interval [CI], 0.49-1.31) or clinically significant GI bleeding (aRR, 0.96; 95% CI, 0.54-1.73). In contrast, delayed resumption was associated with a significantly increased risk of any thromboembolic event (aRR, 2.38; 95% CI, 1.20-4.69), driven primarily by ischemic stroke (aRR, 4.35; 95% CI, 1.49-12.74). Sensitivity analyses restricted to 2019 to 2022 demonstrated consistent findings.

CONCLUSIONS

After elective colonoscopy, delayed DOAC resumption was associated with increased thromboembolic risk without a corresponding reduction in GI bleeding, suggesting thromboembolism risk may warrant greater consideration when determining resumption timing.