Evidence-Based Minireview: Should warfarin or a direct oral anticoagulant be used in patients presenting with thrombosis in the splanchnic or cerebral veins?

Abstract

Case 1: A 23-year-old female third-year medical student who has no medical history seeks treatment for abdominal distention. She takes an estrogen-containing birth control pill and does not smoke or consume alcohol. Family history is unremarkable. Physical examination is significant for abdominal distention, and an abdominal fluid wave is detected. Complete blood count is normal. Imaging confirms occlusive thrombosis of the main portal vein. On endoscopy, grade 1 to 2 esophageal varices are noted and banded. Unfractionated heparin is begun. Subsequent workup reveals a homozygous factor V Leiden mutation. Long-term anticoagulation is planned, and she asks if warfarin can be avoided given her hectic ward rotations, erratic diet, and need for monitoring. Case 2: A 35-year-old woman who has no medical history seeks treatment for progressively worsening posterior headaches for 1 week. Magnetic resonance imaging of the brain shows dural sinus thrombosis with associated small areas of petechial cerebral hemorrhage. She is started on a continuous unfractionated heparin infusion and admitted to the hospital for further observation. Her grandmother is on warfarin for atrial fibrillation, and the patient would prefer to avoid warfarin because she does not think she can comply with the frequent monitoring that will be required. She inquires about other oral anticoagulant options for her condition.

Approach to the patient with non-cirrhotic splanchnic venous thrombosis: a brief narrative review

“…However, retrospective and limited prospective data have demonstrated the safety and effectiveness of DOACs compared to VKAs and LMWH in this cohort of patients (53). For example, Naymagon et al conducted a study comparing the use of DOACs with LMWH and Warfarin for the treatment of non-cirrhotic acute PVT.…”

Shedding Light on the Pathogenesis of Splanchnic Vein Thrombosis

“…The use of DOACs, specific inhibitors of factor Xa or factor IIa, for the treatment of SVT remains contentious [87]. This is due to the registration trials for DOACs only including patients with PE or DVT: the studies do not include patients with any type of SVT, despite their advantages over anti-vitamin Kappa anticoagulants (VKAs) being relevant for patients with unusual site VTE [88][89][90].…”

“…The 2020 ISTH guidelines suggested the possibility of using DOACs in patients without cirrhosis, with acute symptomatic SVT [85]. Retrospective studies and limited prospective data have demonstrated the safety and effectiveness of DOACs compared to VKAs and low molecular weight heparin (LMWH) in this cohort of patients [28,87,91,92]. In a retrospective trial, Naymagon et al compared the use of DOAC (Apixaban, Rivaroxaban and Dabigatran) with LMWH and Warfarin for the treatment of portal vein thrombosis in patients without cirrhosis.…”