Direct oral anticoagulant administration in cirrhotic patients with portal vein thrombosis: What is the evidence?

Abstract

In recent years, the traditional concept that cirrhosis-related coagulopathy is an acquired bleeding disorder has evolved. Currently, it is known that in cirrhotic patients, the hemostatic system is rebalanced, which involves coagulation factors, fibrinolysis and platelets. These alterations disrupt homeostasis, skewing it toward a procoagulant state, which can lead to thromboembolic manifestations, especially when hemodynamic and endothelial factors co-occur, such as in the portal vein system in cirrhosis. Portal vein thrombosis is a common complication of advanced liver cirrhosis that negatively affects the course of liver disease, prognosis of cirrhotic patients and success of liver transplantation. It is still debated whether portal vein thrombosis is the cause or the consequence of worsening liver function. Anticoagulant therapy is the mainstay treatment for acute symptomatic portal vein thrombosis. In chronic portal vein thrombosis, the role of anticoagulant therapy is still unclear. Traditional anticoagulants, vitamin K antagonists and low-molecular-weight heparin are standard-of-care treatments for portal vein thrombosis. In the last ten years, direct oral anticoagulants have been approved for the prophylaxis and treatment of many thromboembolic-related diseases, but evidence on their use in cirrhotic patients is very limited. The aim of this review was to summarize the evidence about the safety and effectiveness of direct oral anticoagulants for treating portal vein thrombosis in cirrhotic patients.

Keywords: Dabigatran; Rivaroxaban; Apixaban; Edoxaban; Bleeding

Core Tip: The role of anticoagulant therapy in portal vein thrombosis is still unclear, especially in partial, chronic and asymptomatic thrombosis. Vitamin K antagonists and low-molecular-weight heparin were demonstrated to be safe and effective, with a positive influence on liver function, portal hypertension and mortality. Direct oral anticoagulants are a new approach to treat portal vein thrombosis in patients with cirrhosis and have many advantages compared to classic anticoagulants, although evidence is still limited. In patients awaiting liver transplantation, dabigatran may be promising for preventing thrombosis progression because of the low rate of hepatotoxicity, predominant renal metabolism and reversibility in perioperative management.