Direct Oral Anticoagulants in Budd-Chiari Syndrome: Need a Closer Look!

We read with interest the retrospective study by Semmler et al1Semmler G. et al.Clin Gastroenterol Hepatol. 2023; 21: 978-987.e2Abstract Full Text Full Text PDF Scopus (6) Google Scholar suggesting the safety and efficacy of long-term anticoagulation with direct oral anticoagulants (DOACs) in patients with Budd-Chiari syndrome (BCS). Almost 73% patients on DOACs had “complete” or “ongoing” response, possibly resulting in 5-year transplant-free survival of more than 90%. The results are encouraging and if confirmed in large prospective studies, use of DOACs might ease the BCS treatment because these drugs have significant advantages over low-molecular-weight heparin/vitamin K antagonist treatment, with no need for international normalized ratio monitoring and no interference with the Model for End-Stage Liver Disease. Certain issues need further consideration. First, the choice and effectiveness of BCS treatment depend on VIKA type of BCS and nature and severity of clinical decompensation. BCS type varies depending on chronology and extent of hepatic vein thrombosis.2Menon K.V. et al.N Engl J Med. 2004; 350: 578-585Crossref PubMed Scopus (431) Google Scholar Interestingly, less than 50% underwent invasive procedures. More so it seems if only patients with acute BCS were enrolled and studied; however, there remains a large subset of patients who present as subacute/chronic BCS having short fibrotic/membranous occlusion of hepatic veins and/or inferior vena cava or complete thrombosis and fibrosis of all 3 native hepatic veins. This subset of patients would majorly require interventions in the form of angioplasty/stenting/transjugular intrahepatic portosystemic shunt (TIPS) and rarely respond to anticoagulation alone. Second, the study enrolled patients over the span of 20 years. The type of TIPS stent (bare metal vs covered stent) used should have been described. Whether TIPS BCS score was calculated for optimizing TIPS use in these patients needs clarification. We need to know the duration of anticoagulant use in patients with treatment failure after invasive procedures. Third, retrospective study design with limited sample size and use of different types of DOACs with different mechanism of action (eg, edoxaban and dabigatran) given in different treatment regimens in 22 patients limit the validity of results. The median time on DOACs was 24.4 months and in 8 of 22 patients, DOACs was stopped after 6 months. Even though patients with “significant liver disease” have been excluded from phase III DOAC trials, DOACs were used in decompensated patients (∼50% had Child-Pugh stage B/C). Recent studies have indicated a higher bleeding risk in patients with more advanced liver disease.3Mort J.F. et al.Clin Gastroenterol Hepatol. 2021; 19: 1436-1442Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,4Semmler G. et al.Liver Int. 2021; 41: 2159-2170Crossref PubMed Scopus (20) Google Scholar In the present study, 5 of 22 patients on DOACs have severe bleeding manifestations. The study should have classified the reasons for substantially high rates of treatment failure (27%) with DOACs in BCS and strategies to optimize the response rates. In conclusion, although early anticoagulation is recommended, the best timing and type has not been evaluated in randomized clinical trials. The choice for the type of anticoagulation should be dictated by pharmacokinetic considerations and by context. Outcome of Budd-Chiari Syndrome Patients Treated With Direct Oral Anticoagulants: An Austrian Multicenter StudyClinical Gastroenterology and HepatologyVol. 21Issue 4PreviewDirect oral anticoagulants (DOACs) may simplify management of Budd-Chiari syndrome (BCS). Here, we report our experience with off-label use of DOACs for anticoagulation in BCS. Full-Text PDF Open AccessReplyClinical Gastroenterology and HepatologyVol. 21Issue 4PreviewWe would like to thank Drs Jindal and Mukund1 for their interest in our study on the use of direct oral anticoagulants (DOACs) in patients with Budd Chiari syndrome (BCS).2 Full-Text PDF