Direct Oral Anticoagulants in Budd-Chiari Syndrome

Area of Science:

• Hepatology
• Hematology
• Pharmacology

Background:

• Budd-Chiari syndrome (BCS) management involves addressing hepatic venous obstruction and anticoagulation.
• Direct oral anticoagulants (DOACs) are effective for other venous thromboembolism but understudied in BCS.

Purpose of the Study:

• To evaluate the efficacy and tolerability of DOACs in primary BCS using available literature.
• To compare DOACs with traditional anticoagulants like vitamin K antagonists (VKA) and low molecular weight heparin (LMWH) in BCS.

Main Methods:

• Systematic review of published studies reporting on BCS patients treated with DOACs.
• Inclusion of two retrospective studies and nine case reports.
• Analysis of outcomes including re-stenosis, treatment failure, and bleeding events.

Main Results:

• Retrospective studies (58 DOAC patients, 101 VKA/LMWH patients) showed similar re-stenosis/failure rates (17.2% DOAC vs. 15.8% VKA/LMWH).
• Major bleeding rates were higher with DOACs (8.62%) compared to VKA/LMWH (5.94%), but minor bleeding was also higher with DOACs (20.7% vs. 4.95%).
• Procedure-related bleeding was lower with DOACs (4.5%) than VKA/LMWH (12.8%). Case reports indicated good tolerability with apixaban, rivaroxaban, and dabigatran.

Conclusions:

• DOACs appear to be at least as effective as VKA/LMWH for anticoagulation in BCS.
• DOACs are potentially preferred due to easier administration.
• Randomized controlled trials are needed to definitively establish the role of DOACs in BCS management.