S1078 Direct-Acting Oral Anticoagulant Use for Atrial Fibrillation and Thromboembolism in Patients With Advanced Cirrhosis

Abstract

INTRODUCTION: Direct acting oral anticoagulants (DOACs) are increasingly used for various indications, however their use in patients with cirrhosis is unclear. These agents are currently not approved for use in Child class C cirrhosis, due to their exclusion from clinical trials and very limited data. METHODS: We performed a retrospective cohort study of all patients with cirrhosis who were prescribed anticoagulants at our tertiary care university hospital from 2010 to 2018. Clinical outcomes between DOAC and warfarin prescriptions were compared. Log-Rank tests and Cox-proportional hazard analysis was conducted to assess the primary outcome of all cause bleeding and secondary endpoint of major bleeding. Subgroup analysis was conducted for Child C cirrhosis. RESULTS: A total of 615 patients with cirrhosis were included [276 participants (44.9%) were female], including 192 patients with Child Class C cirrhosis. 207 patients (33.7%) were prescribed warfarin, while 246 patients (40%) and 160 patients (26%) were prescribed apixaban and rivaroxaban, respectively. The warfarin and DOAC groups were well matched in demographic and clinical baseline characteristics including age, gender, antiplatelet use, history of varices. However, mean MELD-Na score (P = 0.08) and proportion with Child C cirrhosis (P = 0.45) were higher in warfarin group. Ninety-nine patients suffered bleeding events at a mean follow up on anticoagulation of 1.33 years (SD 1.43 years). All-cause bleeding rates were similar between DOAC and warfarin patients, HR: 0.97 (95% CI: 0.62-1.51), [Figures 1 and 2]. Hazard ratio for major bleeding was lower in DOAC group but it failed to achieve statistical significance (HR: 0.599, 95% CI 0.35–1.02). The multivariate cox proportional hazard analysis identified Child Class (P 0.03) and hypoalbuminemia (P = 0.009) as independently associated with an increased risk of bleeding, while choice of anticoagulant was not (P = 0.88). Subgroup analysis of Child C cirrhosis patients did not find any difference between warfarin and DOAC groups in all cause bleeding (log rank P value = 0.7) or major bleeding episodes (log rank P = 0.93). CONCLUSION: DOACs are comparable in bleeding profile to warfarin in patients with cirrhosis including those with Child C cirrhosis.Figure 1.: Primary outcome: all cause bleeding.Figure 2.: Major bleeds.