IDDF2021-ABS-0172 Efficacy and safety of direct oral anticoagulants versus vitamin K antagonists for portal vein thrombosis in cirrhosis: a systematic review and meta-analysis

Background

Portal vein thrombosis (PVT) is associated with a higher risk of liver decompensation, variceal bleeding and long-term mortality in cirrhosis patients. Vitamin K antagonists (VKAs) have a narrow therapeutic range and require frequent dose titration, and the bleeding risk of VKAs in cirrhosis patients is not accurately reflected in the international normalized ratio (INR). Recent American Association for the Study of Liver Diseases (AASLD) guidelines recommend direct-acting oral anticoagulants (DOACs) in cirrhosis patients with non-tumoral PVT. However, the comparative efficacy between DOACs and VKAs for the treatment of cirrhosis with non-tumoral PVT currently remains unknown. We aim to perform a systematic review and meta-analysis to compare the efficacy and safety of DOACs versus VKAs to treat cirrhosis patients with non-tumoral PVT.

Methods

We performed a systematic search of six electronic databases and selected all studies comparing DOACs with VKAs in the treatment of PVT in cirrhosis patients. The primary outcome was either complete or partial PVT recanalization. Secondary outcomes were PVT progression, major bleeding, variceal bleeding and death. (IDDF2021-ABS-0172 Figure 1)

Results

From 943 citations, we included a total of 11 studies (10 observational and 1 randomized trial) evaluating 4 types of DOACs (rivaroxaban, apixaban, edoxaban and dabigatran) that fulfilled the inclusion criteria. 3 studies included patients with Child-Turcott-Pugh (CTP)-C cirrhosis. The overall pooled rate of PVT recanalization, PVT progression, major bleeding and death were 46.0%, 12.9%, 7.9% and 10.2%, respectively. We found that DOACs were associated with a higher pooled rate of PVT recanalization (RR=1.67, 95%CI: 1.02, 2.74, I2=79%) and lower risk of PVT progression (RR= 0.14, 95%CI: 0.03-0.57, I2=0%). The pooled risk of major bleeding (RR= 0.29, 95%CI: 0.08-1.01, I2=0%), variceal bleeding (RR=1.29, 95%CI: 0.64-2.59, I2=0%) and death (RR=0.31, 95%CI: 0.01-9.578, I2=80%) were similar between DOACs and VKAs. (IDDF2021-ABS-0172 Figure 2, IDDF2021-ABS-0172 Figure 3, IDDF2021-ABS-0172 Figure 4)

Conclusions

For the treatment of PVT in patients with cirrhosis, the bleeding risk was comparable between DOACs and VKAs. However, DOACs were associated with a higher pooled rate of PVT recanalization.