ArticleLiver international : official journal of the International Association for the Study of the Liver2021
Safety of direct oral anticoagulants in patients with advanced liver disease.
Article in Liver international : official journal of the International Association for the Study of the Liver, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 23 papers, 2 of them syntheses that pooled it.
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Who cites it
23 citing papers in PubMed, 2 syntheses or guidelines pooled it, 55 citations in OpenAlex.
- Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data.European journal of clinical pharmacology · 2024Pooled it
- Direct Oral Anticoagulants versus Vitamin K Antagonists in Cirrhotic Patients with Atrial Fibrillation: Update of Systematic Review and Meta-Analysis.American journal of cardiovascular drugs : drugs, devices, and other interventions · 2023Pooled it
- Safety and efficacy of direct oral anticoagulants in patients with liver cirrhosis: a meta-analysis.Research and practice in thrombosis and haemostasis · 2026Article
- Thrombotic Risk and Coagulation Imbalance in Cirrhosis and Hepatocellular Carcinoma: Clinical Implications and Management.Cancers · 2025Review
- Venous Thromboembolism in Unusual Locations.The Medical clinics of North America · 2025Review
- Prediction and prevention of post-procedural bleedings in patients with cirrhosis.Clinical and molecular hepatology · 2025Review
- Endothelial Dysfunction and Liver Cirrhosis: Unraveling of a Complex Relationship.International journal of molecular sciences · 2024Review
- Comparative Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Atrial Fibrillation Patients with Chronic Liver Disease: A Systematic Review and Meta-analysis.The Journal of innovations in cardiac rhythm management · 2024Review
- Exploring the Perioperative Use of DOACs, off the Beaten Track.Journal of clinical medicine · 2024Review
- Modest performance of risk-prediction models for anticoagulant-related bleeding in patients with chronic liver disease.Thrombosis research · 2024Article
- Management of varices but not anticoagulation is associated with improved outcome in patients with HCC and macrovascular tumour invasion.Cancer imaging : the official publication of the International Cancer Imaging Society · 2024Article
- Direct oral anticoagulants to treat deep venous thrombosis and pulmonary embolism in patients with cirrhosis: are we there yet?Hematology. American Society of Hematology. Education Program · 2023Article
- Direct oral anticoagulants for the treatment of splanchnic vein thrombosis: A state of art.World journal of gastroenterology · 2023Review
- Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV).Wiener klinische Wochenschrift · 2023Article
- Anticoagulation in Patients with Liver Cirrhosis: Friend or Foe?Digestive diseases and sciences · 2023Review
- Evaluation of recipients with significant comorbidity - Patients with cardiovascular disease.Journal of hepatology · 2023Review
- Management of splanchnic vein thrombosis.JHEP reports : innovation in hepatology · 2023Review
- Major Bleeding After Paracentesis Associated With Apixaban Use: Two Case Reports.Hospital pharmacy · 2023Article
- Improving Management of Portal Hypertension: The Potential Benefit of Non-Etiological Therapies in Cirrhosis.Journal of clinical medicine · 2023Review
- British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 3: special circumstances.Frontline gastroenterology · 2023Article
Corrections and comments
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Authors and funding
15 authors at 2 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
BACKGROUND &
aimsWhile direct oral anticoagulants (DOACs) are increasingly used in patients with liver disease, safety data especially in advanced chronic liver disease (ACLD) are limited.
methodsLiver disease patients receiving DOAC treatment (ACLD: n = 104; vascular liver disease: n = 29) or vitamin K antagonists (VKA)/low-molecular-weight heparin (LMWH; ACLD: n = 45; vascular: n = 13) between January 2010 and September 2020 were retrospectively included. Invasive procedures and bleeding events were recorded. Calibrated anti-Xa peak levels and thrombomodulin-modified thrombin generation assays (TM-TGAs) were measured in a subgroup of 35/28 DOAC patients.
resultsAmong patients receiving DOAC, 55 (41.3%) had advanced liver dysfunction (Child-Pugh-stage [CPS] B/C) and 66 (49.6%) had experienced decompensation. Overall, 205 procedures were performed in 60 patients and procedure-related bleedings occurred in 7 (11.7%) patients. Additionally, 38 (28.6%) patients experienced spontaneous (15 minor, 23 major) bleedings during a median follow-up of 10.5 (IQR: 4.0-27.8) months. Spontaneous bleedings in ACLD patients were more common in CPS-B/C (at 12 months: 36.9% vs CPS-A: 15.9%, subdistribution hazard ratio [SHR]: 3.23 [95% CI: 1.59-6.58], P < .001), as were major bleedings (at 12 months: 22.0% vs 5.0%, SHR: 5.82 [95% CI: 2.00-16.90], P < .001). Importantly, CPS (adjusted SHR: 4.12 [91% CI: 1.82-9.37], P < .001), but not the presence of hepatocellular carcinoma or varices, was independently associated with major bleeding during DOAC treatment. Additionally, ACLD patients experiencing bleeding had worse overall survival (at 12 months: 88.9% vs 95.0% without bleeding; P < .001). Edoxaban anti-Xa peak levels were higher in patients with CPS-B/C (345 [95% CI: 169-395] vs CPS-A: 137 [95% CI: 96-248] ng/mL, P = .048) and were associated with lower TM-TGA. Importantly, spontaneous bleeding rates were comparable to VKA/LMWH patients.
conclusionsAnticoagulants including DOACs should be used with caution in patients with advanced liver disease due to a significant rate of spontaneous bleeding events.
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