The efficacy and safety of direct oral anticoagulants in noncirrhotic portal vein thrombosis

Abstract

Guidelines currently favor vitamin K antagonists or low-molecular-weight heparins for treatment of noncirrhotic portal vein thrombosis (ncPVT). Use of direct oral anticoagulants (DOACs) in PVT has been met with concern because of the lack of data. We conducted a retrospective study to investigate the efficacy and safety of DOACs for the treatment of ncPVT, and to compare them with standard therapies: 330 patients with ncPVT, followed-up for a mean 41.6 months, received warfarin (n = 108), enoxaparin (n = 70), rivaroxaban (n = 65), apixaban (n = 20), dabigatran (n = 8), fondaparinux (n = 2), or no anticoagulation (n = 57). The primary outcome was complete radiographic resolution (CRR) of PVT. Secondary outcomes included recanalization of occlusive PVT, cavernous transformation of the PV, development of chronic portal hypertensive symptoms (cPHS), and major bleeding. DOACs were associated with the highest CRR rates (dabigatran, 6/8 [75%]; apixaban, 13/20 [65%]; rivaroxaban, 42/65 [65%]). Enoxaparin was associated with a CRR rate similar to that of the DOACs (40/70 = 57%). Warfarin was associated with worse outcomes in this regard (CRR rate, 31% [33/108]; hazard ratio [HR] DOACs:warfarin, 2.91; 95% confidence interval [CI], 1.87-4.52; P < .0001). DOACs were associated with recanalization rates similar to enoxaparin and greater than warfarin (HR DOACs:warfarin, 3.45; 95% CI, 1.93-6.18; P < .0001). DOACs were associated with lower rates of cPHS, although this did not attain significance (DOACs, 8/93 [9%]; enoxaparin, 13/70 [19%]; warfarin, 31/108 [29%]). DOACs were associated with less major bleeding relative to warfarin (HR DOACs:warfarin, 0.20; 95% CI, 0.05-0.86; P = .0307). Patients harboring JAK2V617F, those with no evident predisposing factor for PVT, and those with occlusive thrombus demonstrated worse outcomes. DOACs appear effective and safe for the treatment of ncPVT.

Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases

“…( 94,194,195 ) A large, retrospective, single‐center cohort examined 330 patients with PVT without cirrhosis treated with VKAs (n = 108), LMWH (n = 70), DOACs (n = 93), and no anticoagulation (n = 57). ( 196 ) In this cohort, DOAC therapy had superior efficacy (rates of thrombus resolution) and less major bleeding when compared to warfarin. DOAC use offers several advantages over warfarin, including the lack of a need for monitoring and predictable anticoagulant effect (Table 9).…”

Cerebral and Splanchnic Vein Thrombosis: Advances, Challenges, and Unanswered Questions

“…These were mainly small observational studies, either retrospective [97][98][99][100][101][102] or prospective [103], with only one RCT [104]. The number of patients treated with DOAC ranged from 12 [98] to 93 [102] patients. The average anticoagulant treatment duration ranged from 6 [99] to 10.8 [103] months.…”

“…The average anticoagulant treatment duration ranged from 6 [99] to 10.8 [103] months. One study evaluated dabigatran [100], one edoxaban [99], and one rivaroxaban [104], and five cohorts evaluated different DOACs [97,98,[101][102][103]. Three cohorts included patients treated with the DOACs for different clinical indications [97,98,103], and no separate data were reported for SVT patients.…”

Comment on “Next-generation sequencing in the diagnosis of non-cirrhotic splanchnic vein thrombosis”

“…In NC-SVT, anticoagulation has been shown to lead to improved recanalization rates and lower rates of future clinical portal hypertension, and indefinite anticoagulation is generally considered standard among patients with unprovoked NC-SVT who do not have an evident contraindication (as is the case for most patients with a high-risk unprovoked venous thromboembolism). [5][6][7] Another limitation is regarding the variant allele frequency (VAF) of mutations detected on NGS. As the authors note, clonal hematopoiesis of indeterminate potential (CHIP) identifies patients harboring an acquired pathogenic gene mutation without a concurrent identifiable hematologic malignancy.…”