静脉血栓栓塞、慢性肝病与抗凝剂选择：直接口服抗凝剂与华法林的有效性和安全性
Venous thromboembolism, chronic liver disease and anticoagulant choice: effectiveness and safety of direct oral anticoagulants versus warfarin.
作者信息
Lawal Oluwadolapo D, Aronow Herbert D, Hume Anne L, Shobayo Fisayomi, Matson Kelly L, Barbour Marilyn, Zhang Yichi, Wen Xuerong
机构信息
Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA.
Lifespan Cardiovascular Institute, Providence, Rhode Island, USA.
出版信息
Res Pract Thromb Haemost. 2023 Dec 9;8(1):102293. doi: 10.1016/j.rpth.2023.102293. eCollection 2024 Jan.
BACKGROUND
Little to no data exist to guide treatment decision in patients with venous thromboembolism (VTE) and chronic liver disease.
OBJECTIVES
To assess the effectiveness and safety of direct oral anticoagulants (DOACs)-individually and as a class-vs warfarin and between 2 DOACs in patients with acute VTE and chronic liver disease.
METHODS
We conducted a retrospective, US claims-based, propensity score-matched cohort study in adults with acute VTE and chronic liver disease who had newly initiated oral anticoagulants between 2011 and 2017. The primary outcome was a composite of hospitalization for recurrent VTE and hospitalization for major bleeding.
RESULTS
The cohorts included 2361 DOAC-warfarin, 895 apixaban-warfarin, 2161 rivaroxaban-warfarin, and 895 apixaban-rivaroxaban matched pairs. Lower risk of the primary outcome was seen with DOACs (hazard ratio [HR], 0.72; 95% CI, 0.61-0.85), apixaban (HR, 0.48; 95% CI, 0.35-0.66) or rivaroxaban (HR, 0.73; 95% CI, 0.61-0.88) vs warfarin but not apixaban-rivaroxaban (HR, 0.68; 95% CI, 0.43-1.08). The HRs of hospitalization for major bleeding were 0.69 (95% CI, 0.57-0.84) for DOAC-warfarin, 0.43 (95% CI, 0.30-0.63) for apixaban-warfarin, 0.72 (95% CI, 0.58-0.89) for rivaroxaban-warfarin, and 0.60 (95% CI, 0.35-1.06) for apixaban-rivaroxaban. Recurrent VTE risk was lower with apixaban (HR, 0.47; 95% CI, 0.26-0.86), but not DOACs (HR, 0.81; 95% CI, 0.59-1.12) or rivaroxaban vs warfarin (HR, 0.81; 95% CI, 0.57-1.14) or apixaban-rivaroxaban (HR, 0.92; 95% CI, 0.42-2.02).
CONCLUSION
While the magnitude of clinical benefit varied across individual DOACs, in adults with acute VTE and chronic liver disease, oral factor Xa inhibitors (as a class or individually) were associated with lower risk of recurrent VTE and major bleeding.
背景
关于静脉血栓栓塞症（VTE）合并慢性肝病患者的治疗决策，几乎没有数据可供参考。
目的
评估直接口服抗凝剂（DOACs）——作为个体及作为一个类别——与华法林相比，以及两种DOACs之间，在急性VTE合并慢性肝病患者中的有效性和安全性。
方法
我们进行了一项基于美国索赔数据的回顾性倾向评分匹配队列研究，研究对象为2011年至2017年间新开始口服抗凝剂治疗的急性VTE合并慢性肝病成人患者。主要结局是复发性VTE住院和大出血住院的复合结局。
结果
队列包括2361对DOAC-华法林、895对阿哌沙班-华法林、2161对利伐沙班-华法林和895对阿哌沙班-利伐沙班匹配对。与华法林相比，DOACs（风险比[HR]，0.72；95%置信区间[CI]，0.61-0.85）、阿哌沙班（HR，0.48；95%CI，0.35-0.66）或利伐沙班（HR，0.73；95%CI，0.61-0.88）的主要结局风险较低，但阿哌沙班-利伐沙班（HR，0.68；95%CI，0.43-1.08）无此差异。DOAC-华法林大出血住院的HR为0.69（95%CI，0.57-0.84），阿哌沙班-华法林为0.43（95%CI，0.30-0.63），利伐沙班-华法林为0.72（95%CI，0.58-0.89），阿哌沙班-利伐沙班为0.60（95%CI，0.35-1.06）。阿哌沙班的复发性VTE风险较低（HR，0.47；95%CI，0.26-0.86），但DOACs（HR，0.81；95%CI，0.59-1.12）或利伐沙班与华法林相比（HR，0.81；95%CI，0.57-1.14）或阿哌沙班-利伐沙班（HR，0.92；95%CI，0.42-2.02）则无此差异。
结论
虽然不同DOACs的临床获益程度有所不同，但在急性VTE合并慢性肝病的成人患者中，口服Xa因子抑制剂（作为一个类别或个体）与复发性VTE和大出血风险较低相关。
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