Treating thrombosis in cirrhosis patients with new oral agents: Ready or not?

Decreased in vitro anticoagulant potency of Rivaroxaban and Apixaban in plasma from patients with cirrhosis

“…2,3 The report from Intagliata et al of five patients with compensated cirrhosis (Child-Pugh Class A) emphasizing the safety and efficacy of rivaroxaban and apixaban for treatment of acute PVT/ SMV is very encouraging. Similar to our experience (Child-Pugh Class A), complete resolution of the thrombus required a treatment duration of 6 months.…”

“…1 Two recent reports in HEPATOLOGY suggested efficacy and safety of new-generation oral anticoagulant drugs (the direct factor Xa inhibitors, Rivaroxaban and Apixaban) in treatment of PVT in patients with compensated cirrhosis. 2,3 These new drugs have practical advantages over traditional anticoagulants. 4 We recently showed altered in vitro potency of different anticoagulant drugs in patients with cirrhosis, compared to patients with intact liver function.…”

“…The bioavailability of rivaroxaban is higher than apixaban (80% versus 66%) and is dependent on food intake, as it is strongly lipophilic. 2 Both rivaroxaban and apixaban are highly protein bound (87-95%) and it is quite possible that hypoalbuminemia associated with decreased synthetic function in decompensated cirrhosis may result in more active drug and perhaps more anticoagulant activity. Moreover, decompensated cirrhosis may be associated with decreased creatinine clearance from underlying hepatorenal syndrome.…”

Use of nontraditional anticoagulants in portal vein thrombosis: A note of caution

“…We read with great interest the articles by Martinez et al 1 and Intagliata et al 2 in HEPATOLOGY describing the use of nontraditional anticoagulants for treatment of portal and mesenteric vein thrombosis. We agree that newer anticoagulants for portal and mesenteric vein thrombosis are probably effective in some patients.…”

“…Recent publications from Potze et al 1,2 showed decreased in vitro anticoagulant effect of rivaroxaban and apixaban in patients with Child's class B and C cirrhosis, suggesting that these agents may not HEPATOLOGY, Vol. 61, No.…”