Safety of direct‐acting oral anticoagulants relative to warfarin in a matched cohort of liver transplant recipients

Abstract

Despite increasingly widespread utilization of direct-acting oral anticoagulants (DOACs), there remains limited experience with the use of these agents following liver transplantation. We performed a single-center, retrospective review of liver transplant recipients prescribed DOACs or warfarin between January 2014 and January 2018. Patients receiving DOACs were matched with warfarin-treated controls based on discrete clinical parameters and followed from the time of anticoagulant prescription, until treatment discontinuation or study conclusion. The primary endpoint for this review was the incidence of clinically relevant major or non-major bleeding among the treatment groups. Twenty-seven patients prescribed DOACs were identified for inclusion in the review, of which 20 could be matched with suitable warfarin controls. At the conclusion of the study, warfarin-treated patients had a significantly higher incidence of clinically relevant bleeding (45% vs 15%; P = .01). No statistically significant differences were found in the rate of new or recurrent thrombotic events.Multivariable logistic regression demonstrated that warfarin treatment was associated with a significantly higher odds of a bleeding event compared to treatment with a DOAC (OR = 6.9; 95% CI, 1.1-44.6). DOAC use appears relatively safe compared with warfarin in select liver transplant recipients. Patient-specific factors still bear consideration when selecting between the various anticoagulant options. K E Y W O R D Salgorithm, anticoagulants, clotting, hemorrhage, liver transplantation

2020 Clinical Update in Liver Transplantation

“…52 A small retrospective study associated DOACs with less bleeding risk when postoperative transplant patients were matched to warfarin treated controls. 53 While anticoagulation selection should continue to depend on specific patient factors including renal function, drug-drug interactions and insurance coverage, DOACs appear to be safe for use in cirrhotic patients before and after transplantation.…”

Use of direct‐acting oral anticoagulants in solid organ transplantation: A systematic review

“…Prior to 2020, reports on the DOAC use among SOT recipients were limited to single‐center, retrospective case series without control arms (Table 1). 17–42 Among the abstracts from ATC and ISHLT, the incidences of major bleeding (0%–23%) and composite bleeding (0%–37%) ranged widely, and the incidence of thrombotic events was also variable (0%–21%).…”

“…In early 2020, four single‐center retrospective cohort studies were published comparing DOACs to VKAs in SOT recipients 17–20 . Table 2 summarizes the study population, anticoagulants, and efficacy and safety outcomes of the studies 17–20 . The NOS quality assessments for each study were listed in Table 17–20 …”

“…Table 2 summarizes the study population, anticoagulants, and efficacy and safety outcomes of the studies 17–20 . The NOS quality assessments for each study were listed in Table 17–20 …”

“…Researchers 20 compared 27 liver transplant recipients on DOACs to 20 matched controls on warfarin from 2014 to 2018. Patients were excluded with active malignancy, those that stopped anticoagulation prior to 2 months for reasons other than bleeding or thrombosis, and those without appropriate laboratory follow‐up.…”