Abstract

Background:

In patients with Budd Chiari syndrome (BCS), the current treatment guidelines recommend a step-up approach starting with lifelong anticoagulation with low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKA). Although direct oral anticoagulants (DOAC) may simplify patient management, there is limited data on the safety and efficacy of DOAC in patients with BCS. This study used a large research network to compare the outcomes of patients with BCS treated with DOACs, LMWH, and VKAs.

Methods:

In this retrospective cohort study and time-to-event analysis, we utilized the TriNetX electronic health records network, which encompasses over 100 million patients, from January 1st, 2015, to December 31st, 2020. The primary cohort included patients aged 18 years or older diagnosed with BCS. We performed (1:1) propensity score matching age, gender, race, and comorbidities, including Liver Cirrhosis, Diabetes Mellitus, Hypertension, Chronic kidney disease, and malignancy. Two matched control cohorts were created: one consisting of patients with BCS treated with LMWH or VKAs, and the other comprising patients treated with DOACs (including dabigatran, rivaroxaban, apixaban, and edoxaban). Using a Cox model, we estimated the incidence of gastrointestinal bleeding, retroperitoneal hemorrhage, Intracranial hemorrhage, and acute liver failure between propensity score-matched pairs of patients.

Results:

We identified 2,841 patients with BCS who met the inclusion criteria. Among them, 1,997 patients were treated with LMWH or VKAs, while 844 patients were treated with DOACs. Both groups had a majority of female and Caucasian patients, and there were no statistically significant differences in comorbid conditions before and after propensity matching (Table 1). Although there was a higher incidence of acute liver failure in the LMWH/VKA group before propensity matching, this difference did not remain statistically significant after matching. Additionally, there were no significant differences in the incidence of gastrointestinal bleeding, retroperitoneal hemorrhage, and intracranial hemorrhage between the two groups, both before and after propensity matching.

Conclusion:

Based on a large nationwide study, BCS patients treated with DOACs showed comparable rates of gastrointestinal bleeding, retroperitoneal hemorrhage, intracranial hemorrhage, and acute liver failure to those treated with LMWH or VKAs. LMWH or VKA treatment requires continuous monitoring, which may affect patient compliance. Our study suggests that DOACs could serve as an effective and safe long-term anticoagulation alternative for these patients. However, further confirmation through larger prospective studies is necessary.