The Risks of Exfoliative Esophagitis in Patients with Atrial Fibrillation

Abstract

The aging of the population has resulted in atrial fibrillation (AF) becoming increasingly prevalent. Treatment focuses on the prevention of thromboembolism through the use of catheter ablation or drug therapy with anticoagulants, such as warfarin or direct oral anticoagulants (DOACs). Dabigatran-induced exfoliative esophagitis has been reported as a rare side effect of DOACs. Although most cases are mild, some result in severe outcomes. However, the etiology of exfoliative esophagitis remains incompletely understood. The aim of this study is to investigate the etiology of exfoliative esophagitis and identify its risk factors by observational study. The participants were 524 patients using anticoagulants who received catheter ablation for AF and subsequently underwent upper gastrointestinal endoscopy at University of Tsukuba Hospital. Exfoliative esophagitis was noted in 21 (4.0%) patients. Potential risk factors for exfoliative esophagitis were examined retrospectively by comparing patients with and without this condition across the following parameters that were extracted retrospectively from the electronic medical records: physical characteristics, comorbidities, blood-based cardiac markers, echocardiographic and endoscopic findings, and current medications. Regarding physical characteristics, patients with exfoliative esophagitis had significantly higher body weight and BMI. No association was observed between exfoliative esophagitis and comorbidities. Associations were also not found for cardiac markers, echocardiographic findings, or endoscopic findings. In terms of current medications, patients receiving oral dabigatran showed the highest prevalence of exfoliative esophagitis at 8.8% (13/148). The adjusted odds ratio of dabigatran for exfoliative esophagitis was 10.3 by multivariable logistic regression analysis. Obesity and oral dabigatran were found to be significant risk factors for exfoliative esophagitis.

Dabigatran-induced oesophagitis improved by switching medication to apixaban

“…1 Dabigatran is prescribed as a relatively large capsule (18-19 mm in length, 280-390 mg in weight), which can easily get lodged in the oesophagus. 2 It is reported that the size and weight of the capsule affect the oesophageal transit time, and capsules are more likely to adhere to the oesophageal mucosa compared with tablets. 2 3 Therefore, dabigatran has a tendency to get lodged in the oesophagus.…”

“…2 3 Therefore, dabigatran has a tendency to get lodged in the oesophagus. 2 Dabigatran is the only DOAC containing the eluting tartaric acid core, which can cause oesophageal injury. 2 Because dabigatran can dissolve in a strongly acidic environment, it has tartaric acid as the core, which is coated with dabigatran etexilate.…”

“…2 Dabigatran is the only DOAC containing the eluting tartaric acid core, which can cause oesophageal injury. 2 Because dabigatran can dissolve in a strongly acidic environment, it has tartaric acid as the core, which is coated with dabigatran etexilate. 2 The pH of tartaric acid is 2.4; a significantly acidic environment is created.…”

“…2 Because dabigatran can dissolve in a strongly acidic environment, it has tartaric acid as the core, which is coated with dabigatran etexilate. 2 The pH of tartaric acid is 2.4; a significantly acidic environment is created. 2 Instructing patients to take dabigatran orally with a large amount of water and to maintain an upright position for a while after taking it have been reported as effective ways to prevent dabigatran from lodging in the oesophagus.…”

“…2 The pH of tartaric acid is 2.4; a significantly acidic environment is created. 2 Instructing patients to take dabigatran orally with a large amount of water and to maintain an upright position for a while after taking it have been reported as effective ways to prevent dabigatran from lodging in the oesophagus. 2 For patients who cannot continue taking dabigatran due to side effects, switching…”