Efficacy and safety of direct oral anticoagulants versus traditional anticoagulants in cirrhotic patients with venous thromboembolism and atrial fibrillation: a systematic review and meta-analysis.

BACKGROUND

Cirrhosis results in complex modifications of the hemostatic system, creating both an increased risk of thrombosis and a propensity for bleeding. Historically, anticoagulation in patients with liver disease has relied on vitamin K antagonists (VKAs) and low-molecular-weight heparins (LMWHs). More recently, direct oral anticoagulants (DOACs) have been introduced into treatment guidelines for venous thromboembolism (VTE), supported by findings from large phase III clinical trials. However, these trials have mostly excluded individuals with significant liver disease; thus, management of cirrhotic patients with VTE and atrial fibrillation (AF) is informed primarily by retrospective and real-world studies.

MATERIALS AND

METHODS

To evaluate the safety and efficacy of DOACs in cirrhosis, we conducted a systematic review and meta-analysis. The MEDLINE, Google Scholar, EMBASE, and Cochrane databases were searched for studies comparing DOACs with traditional anticoagulants (VKAs, LMWHs) in patients with cirrhosis. A total of 26 studies comprising 11,258 patients with cirrhosis (predominantly with Child class A and B) were included.

RESULTS

DOAC use was associated with a significant reduction in thrombotic events (relative risk [RR] 0.72, 95% CI 0.52-0.98) compared to VKAs. Furthermore, DOACs were associated with a significant reduction in major bleeding risk (odds ratio [OR] 0.63, 95% CI 0.47-0.85).

CONCLUSIONS

DOAC appear to offer a favorable treatment option for cirrhotic patients with VTE or AF and compensated Child-Pugh A or B disease, demonstrating an improved balance between efficacy and safety compared to traditional anticoagulants. Given the predominantly observational evidence base, these findings should be considered hypothesis-generating, particularly for patients with decompensated cirrhosis.