Newer Oral Anticoagulants in the Treatment of Acute Portal Vein Thrombosis in Patients with and without Cirrhosis

Abstract

Background Newer oral anticoagulants (NOACs) are being utilized increasingly for the treatment of venous thromboembolism (VTE). NOAC use is the standard of care for stroke prophylaxis in nonvalvular atrial fibrillation and treatment of acute VTE involving extremities and pulmonary embolism. In contrast, most guidelines in the literature support the treatment of acute portal vein thrombosis (PVT) with low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Literature evaluating NOAC use in the treatment of acute portal vein thrombosis is sparse. This review focuses on the safety and efficacy of the use of NOACs in the treatment of acute PVT in patients, with or without concomitant cirrhosis, based on the most recent data available in the current literature. Methods A systematic review was conducted through a series of advanced searches in the following medical databases: PubMed, BioMed Central, Cochrane, and Google Scholar. Keywords utilized were as follows: NOAC, DOAC (direct oral anticoagulants), portal vein thrombosis, rivaroxaban, apixaban, dabigatran, and edoxaban. Articles related to newer anticoagulant use in patients with portal vein thrombosis were included. Results The adverse events, including bleeding events (major and minor) and the failure of anticoagulation (propagation of thrombus or recurrence of PVT), are similar between the NOACs and traditional anticoagulants for the treatment of acute PVT, irrespective of the presence of cirrhosis. Conclusions Newer oral anticoagulants are safe and efficacious alternatives to traditional anticoagulation with low molecular weight heparin and vitamin K antagonists in the treatment of acute portal vein thrombosis with or without cirrhosis.

Recent developments in the field of vascular liver diseases

“…69,70 The use of direct oral anticoagulants has been evaluated in splanchnic vein thromboses. Although the use of direct oral anticoagulants for Budd-Chiari syndrome and portal vein thrombosis is rapidly increasing, [71][72][73][74] studies remain limited if not anecdotal. Indeed, the small numbers of patients in studies evaluating Budd-Chiari syndrome, recent portal vein thrombosis and portal cavernoma in the absence of cirrhosis, 31,52 and portal vein thrombosis in patients with cirrhosis, 65 prevents drawing any conclusions and making any recommendations.…”

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

“…Direct‐acting oral anticoagulants (DOACs) or non‐VKA oral anticoagulants like dabigatran, rivaroxaban, apixaban, and edoxaban have emerged as an effective alternative to VKAs in the management of patients requiring anticoagulation. A recent systematic review of 10 studies reported that adverse events, including both major and minor bleeding events and failure of anticoagulation, as suggested by propagation of thrombus or recurrence of portal vein thrombosis, were similar between DOACs and VKAs for the treatment of acute portal vein thrombosis, irrespective of the presence of cirrhosis . Dabigatran, an important DOAC, is a direct thrombin inhibitor, and it does not rely on the presence of antithrombin for its action.…”

“…A recent systematic review of 10 studies reported that adverse events, including both major and minor bleeding events and failure of anticoagulation, as suggested by propagation of thrombus or recurrence of portal vein thrombosis, were similar between DOACs and VKAs for the treatment of acute portal vein thrombosis, irrespective of the presence of cirrhosis. 8 Dabigatran, an important DOAC, is a direct thrombin inhibitor, and it does not rely on the presence of antithrombin for its action. Its clearance is via renal excretion in 80% individuals, and its pharmacokinetic profiles remain unaltered in patients with Child A and B cirrhosis.…”

Retrospective analysis of the efficacy and safety of rivaroxaban in the treatment of hepatic sinus obstruction syndrome caused by Gynura segetum

“…Rivaroxaban has been increasingly used as an alternative to warfarin for the prevention of thrombosis in patients with venous thromboembolism (VTE) and atrial fibrillation [10] . It has been widely used in the treatment of deep venous thrombosis and pulmonary embolism.…”

“…The preventive dose is 10 mg once a day, and the therapeutic dose is 15 mg twice a day to 20 mg twice a day. Rivaroxaban can also be used in the treatment of portal vein thrombosis (PVT) in patients with and without cirrhosis [10,11] . However, in the current research and guidelines, the anticoagulant treatment of venous thromboembolism of atypical location (VTE-AL), such as the spleen, kidney, mesentery and portal vein, is still dominated by low molecular weight heparin and warfarin.…”