Abstract

Background: Treating portal vein thrombosis in patients with cirrhosis becomes increasingly challenging when there is also significant thrombocytopenia (<50*10³/uL). As suggested by various international medical societies, a 50% reduction in the standard anticoagulation dosage has been recommended for individuals with significant thrombocytopenia. In this study, our goal was to evaluate the safety of using reduced doses of direct oral anticoagulants (DOAC) among cirrhotic patients who have PVT and coexisting significant thrombocytopenia.

Methods: Adult patients 18 years and old with the diagnosis of cirrhosis and significant thrombocytopenia, as defined by platelet count between 30 and 49*10³/uL, were identified using TriNetX between 2007 and 2020. TriNetx includes a total of 106 different health care organizations from 14 different countries. Patients with cirrhosis with significant thrombocytopenia were divided into two cohorts; the first cohort comprised patient receiving 50% reduced-dose DOAC (Apixaban or Rivaroxaban), and a second cohort did not receive any anticoagulation therapy. We compared the rate of mortality and significant bleeding such as intracranial bleeding and gastrointestinal bleeding between propensity matched (PSM) pairs of patients.

Results: A total of 2,245 patients with cirrhosis and significant thrombocytopenia were included in this analysis. Of these 16% (n=350) were on DOAC, and 84% (n=1,890) were not on anticoagulation. The raw data showed a higher rate of key comorbidities in the DOAC group, such as chronic heart failure (21.7% vs 7.1%, P<0.001), diabetes mellitus (51.0% vs 29.9%, P<0.001), and CKD (35.8% vs 13.9%, P<0.001). Subsequently, two well-matched cohorts were created using a 1:1 propensity-scored matching model (329/329). No significant difference was noted between the two groups in the rate major bleedings at 6 or 12 months. At 6-months intracranial hemorrhage (3.04% vs 3.04%, P=1.00), gastrointestinal bleeding (16.41% vs 12.15%, p=0.475), and over-all mortality (20.97% vs 21.58%, P=0.84). At 12-months intracranial hemorrhage (3.04% vs 3.04%, P=1.00), gastrointestinal bleeding (19.14% vs 14.28%, P=0.09), and over-all mortality (24.62% vs 24.62%, P=1.00).

Conclusion: In a large multi-country study, the use of reduced dosed DOAC in patient with cirrhosis and significant thrombocytopenia was not significantly associated with major bleedings such as intracranial hemorrhage or gastrointestinal bleeding up to 12-months when compared with patient not on anticoagulation.