Research and practice in thrombosis and haemostasis · 2025
Activated charcoal neutralization restores accurate Model for End-Stage Liver Disease and Child-Pugh scores in patients with cirrhosis on direct oral anticoagulant therapy.
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Habay Capucine, Riescher Tuczkiewicz Alix, Ben Salah Imen, Trichet Catherine, Gay Juliette, Durand François, Rautou Pierre-Emmanuel, Roux Olivier, De Raucourt Emmanuelle
Аннотация
BACKGROUND: The use of direct oral anticoagulants (DOACs) is increasingly common, including among patients with cirrhosis. These treatments interfere with coagulation tests, altering the Model for End-Stage Liver Disease (MELD) and Child-Pugh scores, which are critical for assessing disease severity and prioritizing patients on liver transplant waiting lists.
OBJECTIVE: To evaluate the impact of rivaroxaban and apixaban on MELD and Child-Pugh scores and assess charcoal-based neutralization.
METHODS: We investigated the in vitro impact of rivaroxaban and apixaban, at concentrations corresponding to peak plasma levels (300 ng/mL and 150 ng/mL, respectively), on the calculation of these scores. A total of 35 plasma samples from patients with cirrhosis (prothrombin level [PT%]: 13%-104%) were analyzed. INR (international normalized ratio) and PT% were measured before supplementation, after supplementation with rivaroxaban or apixaban, and after DOAC neutralization using activated charcoal (DOAC-Stop).
RESULTS: Rivaroxaban and apixaban supplementation led to an increase in INR (median: 2.81 and 0.70, respectively), resulting in a median overestimation of the MELD score by 12 and 4 points, respectively. PT% was underestimated (median: 70% for rivaroxaban and 48% for apixaban), which impacted the Child-Pugh classification in 4 and 2 patients, respectively. Neutralization of rivaroxaban and apixaban with activated charcoal resulted in INR and PT% values that were comparable to baseline measurements and remained within the analytical variability of the method.
CONCLUSION: These findings highlight the importance of identifying patients on DOAC therapy and implementing neutralization techniques to avoid overestimating disease severity. DOAC-Stop effectively eliminates rivaroxaban- and apixaban-related interference, even in this specific population of patients with cirrhosis who sometimes have profoundly decreased PT% values. Failure to account for DOAC interference could lead to mismanagement and errors in prioritizing patients for liver transplantation.
OBJECTIVE: To evaluate the impact of rivaroxaban and apixaban on MELD and Child-Pugh scores and assess charcoal-based neutralization.
METHODS: We investigated the in vitro impact of rivaroxaban and apixaban, at concentrations corresponding to peak plasma levels (300 ng/mL and 150 ng/mL, respectively), on the calculation of these scores. A total of 35 plasma samples from patients with cirrhosis (prothrombin level [PT%]: 13%-104%) were analyzed. INR (international normalized ratio) and PT% were measured before supplementation, after supplementation with rivaroxaban or apixaban, and after DOAC neutralization using activated charcoal (DOAC-Stop).
RESULTS: Rivaroxaban and apixaban supplementation led to an increase in INR (median: 2.81 and 0.70, respectively), resulting in a median overestimation of the MELD score by 12 and 4 points, respectively. PT% was underestimated (median: 70% for rivaroxaban and 48% for apixaban), which impacted the Child-Pugh classification in 4 and 2 patients, respectively. Neutralization of rivaroxaban and apixaban with activated charcoal resulted in INR and PT% values that were comparable to baseline measurements and remained within the analytical variability of the method.
CONCLUSION: These findings highlight the importance of identifying patients on DOAC therapy and implementing neutralization techniques to avoid overestimating disease severity. DOAC-Stop effectively eliminates rivaroxaban- and apixaban-related interference, even in this specific population of patients with cirrhosis who sometimes have profoundly decreased PT% values. Failure to account for DOAC interference could lead to mismanagement and errors in prioritizing patients for liver transplantation.