1102 Direct Oral Anticoagulants May Be Used in the Treatment of Portal Vein Thrombosis in Patients With Cirrhosis: A Systematic Review and Comparative Meta-Analysis

Abstract

INTRODUCTION: Well-defined guidelines for the treatment of portal vein thrombosis (PVT) in patients with cirrhosis do not exist due to lack in robust data. Treatment options include low molecular weight heparin (LMWH), vitamin K antagonists (VKAs), and the newer direct anticoagulants (DOACs). Anticoagulation safety has been an issue in patients with cirrhosis, and the best choice of anticoagulation is unknown. METHODS: We conducted a comprehensive search of multiple databases and conference proceedings (through November 2018) to identify studies that reported on the use of LMWH, VKAs, and DOACs in the treatment of PVT in patients with cirrhosis. Goals were to evaluate the pooled rate of treatment success and bleeding with LMWH, VKAs, and DOACs, and indirectly compare the outcomes. RESULTS: From a total of 744 patients (17 studies), 648 were treated with some form of anticoagulation and 96 were control. 155, 315, and 70 patients were treated with LMWH, VKAs, and DOACs respectively. Baseline characteristics were comparable among the groups. Age ranged from 41 to 71 years with a predominantly male population. 144 patients were Childs A, 182 Childs B, and 121 Childs C. Pooled rate of treatment responders with anticoagulation was 66.7% (95% CI 58.3-74.1, I2 = 72.7) and with control was 26% (95% CI 14.2-42.7, I2 = 36.7). The difference was statistically significant, P = 0.001. Pooled rate of bleeding was similar between these two groups (7.8%, 95% CI 4.5-13.3 and 15.4%, 95% CI 4.3-42.7, P = 0.33). Pooled rates of treatment success and bleeding events were comparable between LMWH, VKAs, and DOACs (Table 1). On meta-regression analysis, Child-Pugh classification did not seem to affect the treatment success and/ or the bleeding outcomes. The calculated 2-sided P-value of intercept was 0.39, Childs A was 0.15, Childs B was 0.11, and Childs C was 0.15. CONCLUSION: Our study demonstrates that anticoagulation is effective and safe in the treatment of PVT in patients with cirrhosis. Bleeding is not increased in treatment group compared to control group. Due to their similar and comparable outcomes, DOACs may be offered as a first line treatment based on patient preferences. Limitations of our study were the comparatively small sample size of patients on DOACs, heterogeneity, and indirect comparison. Well-conducted studies are warranted to ascertain the role of DOACs in the treatment of PVT in patients with cirrhosis.