Background

The most common side effect of oral anticoagulants are bleeding complications. In large trials, novel direct oral anticoagulants (NOAC) have been shown to reduce the risk of major bleeding compared to warfarin. However, little is known about the distribution pattern, management and outcome of NOAC-related bleeding complications in daily care.

Patients and methods

Using data from a large regional registry of patients treated with novel direct oral anticoagulants (NOAC) in the district of Saxony, Germany, we evaluated pattern and management of NOAC-related bleeding complications in daily care. In this ongoing registry, a network of 239 physicians enrols up to 2500 daily care NOAC patients who receive central prospective follow up (FU) by the registry office at day 30 day and quarterly thereafter to collect efficacy and safety data. All outcome events are centrally adjudicated using standard scientific definitions.

Results

Until July 31th 2013, 2249 patients were enrolled into the registry. Of these, 1738 (77.3%) patients received rivaroxaban, 356 (15.8%) received dabigatran and 155 (6.9%) received apixaban. During follow-up (2674.0 patient years), a total of 825 patients reported 1137 bleeding complications (59.1% minor, 33.9% non-major, clinically relevant (NMCR) and 6.9% major bleeding according to ISTH definition).

For non-major bleedings, mucosal and skin bleeding were the most common bleeding sites (67.9% of all bleedings), followed by genitourinary (10.9%) and gastrointestinal bleeding (10.9%). For major bleeding, gastrointestinal bleeding was the most common manifestation (2.8%), followed by genito-urinary (0.6%) bleeding.

In 93% of all bleeding events, treatment was not necessary or consisted of conservative treatment with compression, tamponade or red blood transfusion. Surgical or interventional treatment was reqired in 7.0% of all bleedings (0.0% of minor, 13.0% of NMCR and 38.0% of major bleedings). Prothrombin complex concentrate was used in 1.3% (24% of all major bleedings). No patient received recombinant factor VII.

Bleeding-associated mortality was 0.5% for all and 7.5% for major bleeding. Of the six fatal bleedings observed, three were intracranial bleedings.

Conclusion

Bleeding complications are common in daily care NOAC patients and are usually managed conservatively. Only 7% of all observed bleedings fulfil the ISTH criteria of major bleeding (mainly for RBC transfusion criterion) and are managed using interventions, FFP or PCC.

Overall, only few NOAC-associated bleeding complications in daily care are fatal, indicating that available management strategies are sufficient.

For presentation at ASH, updated results including risk assessments will be reported.

Disclosures:

Werth:Bayer Healthcare: Honoraria. Beyer-Westendorf:Bayer Healthcare: Research Funding, Speakers Bureau; Boehringer Ingelheim: Research Funding, Speakers Bureau; Pfizer: Research Funding, Speakers Bureau.

Table 1

pattern, management and outcome of bleeding complications with NOAC therapy in daily care.

Bleeding type/therapyn / 1137
(%)
None or
compression/ tamponade or
transfusion
only
Surgery or
intervention
RBCFFPPCCrVIImortality
Minor bleeding 672 (59.1) 672 (100.0) 0 0 0 0 0 0 
-Mucosal (epistaxis, gingival, conjunctival) 356/672
(53.0) 
356 
- Skin (traumatic skin bleed, bruises) 187/672
(27.8) 
187 
-Respiratory tract 12/672
(1.8) 
12 
- Gastrointestinal 66/672
(9.8) 
66 
-Genito-urinary 51/672
(7.6) 
51 
NMCR 386 (33.9) 336 (87.0) 50 (13.0) 2 (0.5) 0 0 0 0 
-Mucosal (epistaxis, gingival, conjunctival) 119/386
(30.8) 
100 19 
- Skin (traumatic skin bleed, bruises) 110/386
(28.5) 
97 13 
-Respiratory tract 7/386
(1.8) 
- Gastrointestinal 58/386
(15.0) 
50 
-Genito-urinary 73/386
(18.9) 
67 
-intraabdominal/retro-peritoneal 2/386
(0.5) 
- other 16/386
(4.1) 
13 
Major 80 (7.0) 50
(62.5) 
30
(37.5) 
50
(62.5) 
8
(10.0) 
9
(11.3) 
0 6
(7.5) 
-Mucosal (epistaxis, gingival, conjunctival) 2/80
(2.5) 
- Skin (traumatic skin bleed, bruises) 5/80
(6.3) 
- Respiratory tract 1/80
(1.3) 
-Gastrointestinal 32/80
(40.5) 
19 13 26 
-Genito-urinary 7/80
(8.9) 
-intraabdominal/retro-peritoneal 1/80
(1.3) 
- intracranial 3/80
(3.8) 
- intraocular 4/80
(5.1) 
-mediastinal 1/80
(1.3) 
- pericardial 2/80
(2.5) 
- other 21/80
(26.6) 
20 18 
TOTAL 1137
(100) 
1057 (93.0) 80
(7.0) 
52 (4.6) 8 (0.7) 9 (0.8) 0 6
(0.5) 
Bleeding type/therapyn / 1137
(%)
None or
compression/ tamponade or
transfusion
only
Surgery or
intervention
RBCFFPPCCrVIImortality
Minor bleeding 672 (59.1) 672 (100.0) 0 0 0 0 0 0 
-Mucosal (epistaxis, gingival, conjunctival) 356/672
(53.0) 
356 
- Skin (traumatic skin bleed, bruises) 187/672
(27.8) 
187 
-Respiratory tract 12/672
(1.8) 
12 
- Gastrointestinal 66/672
(9.8) 
66 
-Genito-urinary 51/672
(7.6) 
51 
NMCR 386 (33.9) 336 (87.0) 50 (13.0) 2 (0.5) 0 0 0 0 
-Mucosal (epistaxis, gingival, conjunctival) 119/386
(30.8) 
100 19 
- Skin (traumatic skin bleed, bruises) 110/386
(28.5) 
97 13 
-Respiratory tract 7/386
(1.8) 
- Gastrointestinal 58/386
(15.0) 
50 
-Genito-urinary 73/386
(18.9) 
67 
-intraabdominal/retro-peritoneal 2/386
(0.5) 
- other 16/386
(4.1) 
13 
Major 80 (7.0) 50
(62.5) 
30
(37.5) 
50
(62.5) 
8
(10.0) 
9
(11.3) 
0 6
(7.5) 
-Mucosal (epistaxis, gingival, conjunctival) 2/80
(2.5) 
- Skin (traumatic skin bleed, bruises) 5/80
(6.3) 
- Respiratory tract 1/80
(1.3) 
-Gastrointestinal 32/80
(40.5) 
19 13 26 
-Genito-urinary 7/80
(8.9) 
-intraabdominal/retro-peritoneal 1/80
(1.3) 
- intracranial 3/80
(3.8) 
- intraocular 4/80
(5.1) 
-mediastinal 1/80
(1.3) 
- pericardial 2/80
(2.5) 
- other 21/80
(26.6) 
20 18 
TOTAL 1137
(100) 
1057 (93.0) 80
(7.0) 
52 (4.6) 8 (0.7) 9 (0.8) 0 6
(0.5) 

RBC = red blood cell, FFP = fresh frozen plasma, PCC = prothrombin complex concentrate, rVII = recombinant Factor VII, NMCR = non-major, clinically relevant bleeding.

Author notes

*

Asterisk with author names denotes non-ASH members.

This icon denotes a clinically relevant abstract

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