Direct oral anticoagulants and warfarin in patients with cirrhosis: a comparison of outcomes

Anticoagulation management in patients with cirrhosis presents several challenges as a result of alterations in hemostasis. Historically vitamin k antagonists and low molecular weight heparins have been the agents of choice in this patient population. Direct oral anticoagulants (DOACs) may provide an alternative to traditional anticoagulant therapy. To evaluate the rate of major bleeding among patients receiving DOACs or warfarin with cirrhosis. A retrospective, observational, cohort study of adult patients admitted between January 2012 and July 2018 with diagnosis of cirrhosis receiving anticoagulation with DOAC or warfarin therapy was performed. Patients were stratified based on the receipt of a DOAC or warfarin. The primary endpoint was incidence of major bleeding at 90 days. Secondary endpoints included stroke or embolic event at 90 days as well as rehospitalization and mortality at 1 year. One hundred sixty-seven patients were included for analysis; of which 110 received warfarin and 57 received a DOAC. The most commonly used DOAC was apixaban (52.6%) followed by rivaroxaban (45.6%) and dabigratran (1.8%). The incidence of major bleeding was similar between warfarin and DOAC groups (9.1% vs. 5.2% p = 0.381). No difference in the rate of stroke or recurrent embolic event at 90 days was identified between the two groups (0% vs. 1.58% p = 0.341; 1.8% vs. 1.8% p = 0.731). In conclusion DOACs appear to be a safe alternative to warfarin in patients with mild to moderate cirrhosis. Further studies are warranted to confirm these findings.