Cheng Han Ng1, Darren Jun Hao Tan2, Kameswara Rishi Yeshayahu Nistala2, Nicholas Syn2,3, Jieling Xiao2, Eunice Xiang Xuan Tan2,4,5, Felicia Zuying Woo6,4, Nicholas W S Chew7, Daniel Q Huang2,4,5, Yock Young Dan2,4,5, Arun J Sanyal8, Mark D Muthiah9,10,11. 1. Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore. chenhanng@gmail.com. 2. Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore. 3. Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore. 4. National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore. 5. Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore. 6. Department of Pharmacy, National University Hospital, Singapore, Singapore. 7. Division of Cardiology, Department of Medicine, National University Hospital, Singapore, Singapore. 8. Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA. 9. Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore. mdcmdm@nus.edu.sg. 10. National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore. mdcmdm@nus.edu.sg. 11. Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore. mdcmdm@nus.edu.sg.
Abstract
BACKGROUND: Current guidelines have limited consensus on the approach to portal venous thrombosis (PVT) in cirrhotic patients. While there is rising interest in direct oral anticoagulants (DOACs) use for PVT, current evidence is limited by small sample size and lack of comparisons to traditional anticoagulants. Thus, a network meta-analysis was conducted to compare the use of DOACs with traditional anticoagulants. METHODS: Medline and Embase were searched for articles about anticoagulation use in cirrhotic patients with nontumorous PVT for articles on DOACs, warfarin, low-molecular weight heparin (LMWH) or antithrombin III. A network analysis was conducted using risk ratios (RR) with surface under the cumulative ranking curve (SUCRA). A single-arm meta-analysis was used to summarize the outcomes of DOAC treatment. RESULTS: A total of 10 articles were included in the study. 79.5% (CI 38.8-95.9) of DOACs patients achieved complete or partial recanalization and 9.80% (CI 4.50-20.0) experienced a bleeding event. DOACs were superior to LMWH (RR 2.299, CI 1.037-5.093, p = 0.040), warfarin (RR 1.762, CI 1.017-3.053, p = 0.043) and no treatment (RR 3.489, CI 1.394-8.733, p = 0.008) in complete recanalization. For partial recanalization, while DOACs were not superior to any treatment, they had the highest probability in achieving partial recanalization in SUCRA analysis. Bleeding risk and mortality were similar compared to other treatments. CONCLUSION: The network analysis supports the use of DOACs in cirrhotic patients, with significant rates of complete recanalization compared to other treatments without increasing bleeding risk. DOACs can potentially be considered for nontumorous PVT in cirrhosis.
BACKGROUND: Current guidelines have limited consensus on the approach to portal venous thrombosis (PVT) in cirrhotic patients. While there is rising interest in direct oral anticoagulants (DOACs) use for PVT, current evidence is limited by small sample size and lack of comparisons to traditional anticoagulants. Thus, a network meta-analysis was conducted to compare the use of DOACs with traditional anticoagulants. METHODS: Medline and Embase were searched for articles about anticoagulation use in cirrhotic patients with nontumorous PVT for articles on DOACs, warfarin, low-molecular weight heparin (LMWH) or antithrombin III. A network analysis was conducted using risk ratios (RR) with surface under the cumulative ranking curve (SUCRA). A single-arm meta-analysis was used to summarize the outcomes of DOAC treatment. RESULTS: A total of 10 articles were included in the study. 79.5% (CI 38.8-95.9) of DOACs patients achieved complete or partial recanalization and 9.80% (CI 4.50-20.0) experienced a bleeding event. DOACs were superior to LMWH (RR 2.299, CI 1.037-5.093, p = 0.040), warfarin (RR 1.762, CI 1.017-3.053, p = 0.043) and no treatment (RR 3.489, CI 1.394-8.733, p = 0.008) in complete recanalization. For partial recanalization, while DOACs were not superior to any treatment, they had the highest probability in achieving partial recanalization in SUCRA analysis. Bleeding risk and mortality were similar compared to other treatments. CONCLUSION: The network analysis supports the use of DOACs in cirrhotic patients, with significant rates of complete recanalization compared to other treatments without increasing bleeding risk. DOACs can potentially be considered for nontumorous PVT in cirrhosis.
Authors: Kirstine Kobberøe Søgaard; Erzsébet Horváth-Puhó; Henning Grønbaek; Peter Jepsen; Hendrik Vilstrup; Henrik Toft Sørensen Journal: Am J Gastroenterol Date: 2009-01 Impact factor: 10.864
Authors: Frits I Mulder; Floris T M Bosch; Annie M Young; Andrea Marshall; Robert D McBane; Tyler J Zemla; Marc Carrier; Pieter Willem Kamphuisen; Patrick M M Bossuyt; Harry R Büller; Jeffrey I Weitz; Saskia Middeldorp; Nick van Es Journal: Blood Date: 2020-09-17 Impact factor: 22.113
Authors: José A López-López; Jonathan A C Sterne; Howard H Z Thom; Julian P T Higgins; Aroon D Hingorani; George N Okoli; Philippa A Davies; Pritesh N Bodalia; Peter A Bryden; Nicky J Welton; William Hollingworth; Deborah M Caldwell; Jelena Savović; Sofia Dias; Chris Salisbury; Diane Eaton; Annya Stephens-Boal; Reecha Sofat Journal: BMJ Date: 2017-11-28