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Meta-Analysis
. 2024 Jan-Dec:30:10760296241301402.
doi: 10.1177/10760296241301402.

Comparison of the Efficacy and Safety of Direct Oral Anticoagulants and Warfarin in Cirrhotic Patients: A Systematic Review and Meta-Analysis

Chunwei Cheng  1 , Juan Hua  2 , Liang Xiong  2
Affiliations
Meta-Analysis

Comparison of the Efficacy and Safety of Direct Oral Anticoagulants and Warfarin in Cirrhotic Patients: A Systematic Review and Meta-Analysis

Chunwei Cheng et al. Clin Appl Thromb Hemost. 2024 Jan-Dec.

Abstract

Objective: Currently, there is limited evidence regarding the use of direct oral anticoagulants (DOACs) for patients with liver cirrhosis (LC). We performed a meta-analysis to compare the efficacy and safety of DOACs versus warfarin in this population.

Methods: We searched PubMed, Cochrane Library, Web of Science, Embase and Scopus databases from inception to August 2024. Clinical studies comparing the use of DOACs with warfarin in cirrhotic patients were included. Hazard ratios (HRs) with 95% CIs were estimated by either fixed or random effects models. Primary efficacy outcomes were ischemic stroke/thromboembolism (IS/TE) and all-cause death, the primary safety outcomes were the bleeding risks.

Results: Sixteen studies were included (16 829 individuals). DOACs had similar benefits in preventing IS/TE (HR = 0.87, 95% CI: 0.69-1.10), but DOACs were significantly associated with reduced risk of all-cause death (HR = 0.87, 95% CI: 0.79-0.97). On the other hand, we observed significantly reduced risks of any bleeding (HR = 0.60; 95%CI: 0.37-0.95), major bleeding (HR = 0.72; 95%CI: 0.63-0.82), intracranial hemorrhage (ICH) (HR = 0.47; 95%CI: 0.30-0.73), and gastrointestinal bleeding (GIB) (HR = 0.72, 95% CI: 0.60-0.87) in patients receiving DOACs. Results were consistent in cirrhotic patients with AF. Furthermore, DOACs reduced the incidence of major bleeding (HR = 0.65, 95%CI: 0.55-0.78) and ICH (HR = 0.17, 95%CI: 0.04-0.76) in patients with moderate to severe cirrhosis.

Conclusion: Our study demonstrates that DOACs, compared with warfarin, exerted comparable efficacy and better safety and may represent a safer alternative to warfarin in cirrhotic patients.

Keywords: direct oral anticoagulants; liver cirrhosis; meta-analysis; warfarin.

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Conflict of interest statement

Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
The flow chart of the literature search and screening process.
Figure 2.
Figure 2.
The efficacy outcomes of DOACs and warfarin in cirrhotic patients. (A) IS/TE; (B) all-cause death.
Figure 3.
Figure 3.
The safety outcomes of DOACs and warfarin in cirrhotic patients. (A) any bleeding; (B) major bleeding; (C) ICH; (D) GIB.
Figure 4.
Figure 4.
Comparing the efficacy and safety of DOACs with warfarin in patients with cirrhosis and AF. (A) IS/TE; (B) all-cause death; (C) any bleeding; (D) major bleeding; (E) ICH; (F) GIB.
Figure 5.
Figure 5.
Comparing the efficacy and safety of DOACs with warfarin in moderate-severe cirrhosis patients. (A) IS/TE; (B) major bleeding; (C) ICH; (D) GIB.
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