Key result
DOACs cut all bleeding ~24% vs. warfarin or LMWH in patients with liver disease.
Why the study?
The safety of DOACs compared with warfarin or LMWH regarding bleeding events across different severities of liver disease required evaluation.
Do DOACs reduce bleeding events compared to warfarin/LMWH in patients with liver disease?
Meta-Analysis (n=41,447)
Do DOACs reduce bleeding events compared to warfarin/LMWH in patients with liver disease?
Relative Risk: 0.76 (95% CI 0.66–0.87)
In patients with liver disease, DOACs significantly reduce the risk of bleeding and all-cause mortality compared with warfarin or LMWH.
DOACs linked to lower bleeding and death in liver disease; supports observational preference but leaves open need for RCTs before practice change.
BACKGROUND: Direct oral anticoagulants (DOACs), such as apixaban, edoxaban, rivaroxaban, or dabigatran, are an effective treatment for atrial fibrillation (AF) and deep venous thromboembolism. We hope to evaluate the safety of DOACs versus warfarin/low molecular weight heparin (LMWH) in improving bleeding events in patients with different severity of the liver disease. METHODS: We systematically searched the Cochrane Library, PubMed, and Embase databases for studies reporting the effects of DOACs in patients with liver cirrhosis. A random-effects model or fixed-effects model was selected to pool risk ratios (RR) and 95% confidence intervals (CI). RESULTS: A total of 18 studies involving 41,447 participants was included in this meta-analysis. Compare with warfarin/ LMWH, the use of DOACs significantly reduced the incidence of all bleeding (RR: 0.76; 95%CI: 0.66 to 0.87), major bleeding (RR: 0.51; 95%CI: 0.28 to 0.91), intracranial hemorrhage (RR: 0.50; 95%CI: 0.31 to 0.81), and gastrointestinal bleeding (RR: 0.76, 95% CI: 0.60 to 0.97), and all-cause death in patients with liver disease (RR: 0.77; 95%CI: 0.62 to 0.95). Similar results were observed in atrial fibrillation patients with liver disease and cirrhosis subgroups. Furthermore, the pooled estimates of the Child-Turcotte-Pugh (CTP) class indicated that DOACs reduced the incidence of all bleeding (RR: 0.61; 95%CI: 0.45 to 0.82), gastrointestinal bleeding (RR 0.55; 95%CI: 0.37 to 0.83), and all-cause death (RR: 0.62; 95%CI: 0.49 to 0.79) in patients with mild to moderate cirrhosis. CONCLUSIONS: Our study demonstrates that DOACs significantly reduce the risk of bleeding in patients with liver disease compared with warfarin/LMWH.
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Zhao et al. (2022) conducted a meta-analysis in Liver disease (n=41,447). Direct oral anticoagulants (DOACs) vs. Warfarin/low molecular weight heparin (LMWH) was evaluated on All bleeding (RR 0.76, 95% CI 0.66 to 0.87). Direct oral anticoagulants significantly reduced the incidence of all bleeding compared with warfarin or LMWH in patients with liver disease (RR 0.76; 95% CI 0.66-0.87).
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