Gastrointestinal Bleeding Risk and Endoscopy Utilization in COVID-19 Patients on Therapeutic Anticoagulation: A Multicentric Study
Introduction- Patients affected with coronavirus disease 2019 (COVID-19) can lead to severe hypercoagulability. Many of these patients receive therapeutic anticoagulation because of a very high risk of thromboembolism. However, data about the risk of gastrointestinal bleeding (GIB) in these patients on therapeutic anticoagulation is scarce. Additionally, endoscopy utilization among these GIB patients need further studies. This study aims to evaluate the rates of GIB bleeding in COVID-19 patients and the endoscopy utilization for the same from a national research network database.
Methods- We used a federated cloud-based network database named TriNetX, comprising of 50 healthcare organizations (HCOs) across the US to identify all adults patients who were on therapeutic anticoagulation (warfarin, therapeutic dose-heparin [enoxaparin, unfractionated heparin], direct thrombin inhibitors, direct acting factor Xa inhibitors 3-months prior to COVID-19 diagnosis. Patients with the use of anticoagulants for thromboprophylaxis were excluded. Patients with the above characteristics were studied from January 1, 2020, to June 15, 2021, were divided into the anticoagulation (COVID with AC) and without anticoagulation (COVID w/o AC) groups.The primary outcomes were rates of GIB (melena/hematemesis), inpatient hospitalizations, endoscopy (EGD/colonoscopy) utilization, number of packed red blood cell (PRBC) transfusions, and 30-day all-cause mortality. The outcomes were measured after 1:1 propensity matching of the groups based on the baseline demographics and comorbidities.
Results- A total of 104,946 patients in COVID with AC and 591,273 patients in COVID w/o AC groups were compared. The patient comorbidities at presentation, laboratory findings, and clinical outcomes are noted in Table 1. After matching, COVID with AC patients had a higher risk of GIB (risk ratio [RR]- 1.62 (CI- 1.45 - 1.82)), inpatient hospitalization rates (RR- 4.53 (CI- 4.42 - 4.65)), PRBC transfusions (RR 3.67 (CI-3.35 - 4.02)), overall mortality (RR 3.93 (3.75 - 4.12)). Despite the increased presence of GIB, endoscopy utilization was lower (RR0.85 (0.78 - 0.93)).
Discussion- Rates of GIB, inpatient hospitalization, and overall mortality increased in COVID-19 patients on therapeutic anticoagulation. However, endoscopy utilization remained low, probably due to fear of infection transmission. If the increased mortality is related to the underlying severity of COVID-19 or unidentified comorbidities need to be further evaluated.
Perisetti, Abhilash MD; Goyal, Hermant MD; Yendala, Rachana MD; Mahanazuddin, Syed MD; Rojas, Mariajose MD; Gajendran, Mahesh MD; Tharian, Benjamin MD; and Sharma, Neil MD, "Gastrointestinal Bleeding Risk and Endoscopy Utilization in COVID-19 Patients on Therapeutic Anticoagulation: A Multicentric Study" (2021). Other Specialties. 26.