Safety and Efficacy of Direct Oral Anticoagulants in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis

作者：Daniel Tham, Wenhui Yu, Lucy Zhao, Roger Kou, Jayhan Kherani, Pei Ye Li, Shreyas Sreeraman, Ali Eshaghpour, Allen Li, Mark Crowther · 发表于：Blood · 年份：2023 · DOI：10.1182/blood-2023-184638 · 被引用次数：2 · 研究领域：Liver Disease and Transplantation、Venous Thromboembolism Diagnosis and Management、Drug-Induced Hepatotoxicity and Protection

Introduction Direct oral anticoagulants (DOACs) are widely used for treatment of venous thromboembolism (VTE) and stroke prophylaxis in patients with atrial fibrillation. Liver cirrhosis increases the risk of conditions necessitating anticoagulation, but also increases the risk of bleeding, complicating anticoagulation use. Traditionally, low molecular weight heparin (LMWH) or Vitamin K Antagonists (VKA) have been used in this patient population. However, VKA use can be complicated due to difficulty monitoring in the context of synthetic dysfunction and baseline INR abnormalities. DOACs have emerged as alternative agents, with less proposed reliance on hepatic elimination. Apixaban, rivaroxaban, edoxaban and dabigatran are eliminated by the liver at 75%, 65%, 50% and 20% respectively. However, safety data on DOACs in cirrhosis patients is limited due to historic exclusion from larger trials. Patients with severe Child-Pugh (CP) classes are notably underrepresented in major trials. Various guidelines currently classify CP class C (and sometimes B) as contraindications to DOACs. Methods A literature search of MEDLINE and Embase from inception to Jan 2023 identified randomized controlled trials (RCTs) and cohort studies comparing DOACs to LMWH/VKA in cirrhosis patients. Two independent reviewers screened and extracted data at title, abstract, and full-text. Patient characteristics, CP class, and anticoagulation regimens were extracted. The primary outcome was major bleeding per ...