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Direct Oral Anticoagulants in Budd-Chiari Syndrome
Shrinjaya B Thapa1,2, Gabriel Roman Souza1,2, Mahati Paravathaneni1,2
1Department of Hematology/Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.
Insights
Direct oral anticoagulants (DOACs) show comparable efficacy to vitamin K antagonists/low molecular weight heparin in Budd-Chiari syndrome (BCS) patients. DOACs offer administration advantages, warranting further investigation in randomized trials.
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.
Aims:
Budd-Chiari syndrome (BCS) is managed by interventions aimed at relieving hepatic venous obstruction and anticoagulation. Despite robust data supporting the tolerability and efficacy of direct oral anticoagulants (DOACs) in patients with other venous thromboembolism, its utility in BCS is not well documented. This study aims to evaluate the efficacy and tolerability of DOACs in Primary BCS from the available literature.
Methods:
Published studies that reported data on patients with BCS treated with DOACs were included.
Results:
Two retrospective studies and nine case reports met the criteria for inclusion. The combined data from these two retrospective studies include 58 patients administered DOAC and 101 patients treated with VKA/LMWH. The combined re-stenosis or failure rates after percutaneous endovascular intervention, angioplasty, TIPS, or OLT were 17.2% for the DOAC group and 15.8% for the LMWH/VKA group. The incidence of major bleeding was 8.62% in the DOAC group and 5.94% in the LMWH/VKA group, while minor bleeding rates were 20.7% and 4.95%, respectively. Procedure-related bleeding was 4.5% in DOAC group and 12.8% in VKA/LMWH group. Nine case reports using apixaban in 3, rivaroxaban in 5, and one with dabigatran- described patients tolerating the treatment well and experiencing no major adverse events.
Conclusions:
DOACs appear to be at least equally effective to LMWH/VKA for the anticoagulation of patients with BCS. We believe DOACs to be preferred over LMWH/VKA for the anticoagulation of patients with BCS due to the known advantages in administration, but randomized trials might be needed to answer this question.
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