Anticoagulant Use Tied to Improved Outcomes of Portal Vein Thrombosis in IBD

By Will Boggs MD

April 02, 2020

NEW YORK (Reuters Health) - Anticoagulant treatment is associated with better outcomes of portal-vein thrombosis (PVT) related to inflammatory bowel disease (IBD), according to new research.

"Based on the findings in this study, as well as those from another of our recent studies, I would prefer a direct oral anticoagulant (such as rivaroxaban, apixaban, or dabigatran) for first-line treatment of IBD-related PVT (and all non-cirrhotic PVT)," Dr. Leonard Naymagon of Icahn School of Medicine at Mount Sinai, in New York City, told Reuters Health by email.

PVT is a recognized complication of IBD, especially in the setting of acute flares, colorectal surgeries, and infectious complications. Diagnosis of PVT is challenging because its nonspecific symptoms (such as abdominal pain) can occur in the same settings.

Dr. Naymagon and colleagues evaluated the natural history, treatments and outcomes of PVT in 63 patients with IBD (26 with Crohn disease and 37 with ulcerative colitis) who were followed for a median 21 months.

Of these patients, 47 (75%) had an additional clinically evident provoking factor for PVT besides IBD, most often recent intra-abdominal surgery or intra-abdominal infection.

Initial presentations and laboratory results were nonspecific, and a third of patients were thought by a gastroenterologist to be in acute IBD flare.

In all cases, the diagnosis of PVT was made by CT (79%) or MRI (21%). A third of patients had completely occlusive thrombosis of the portal vein, and more than half had PVT extending into a portal-vein tributary.

All but five patients (92%) received anticoagulant therapy, which started within three days of diagnosis with intravenous heparin and was transitioned to an oral or subcutaneous anticoagulant a median three days later.

All anticoagulated patients received at least three months of anticoagulation, with a median course of treatment of 3.9 months for the 23 patients receiving direct oral anticoagulants (DOACs) and 8.5 months for the 22 patients receiving warfarin.

Overall, 45 patients (71%) achieved the primary outcome of complete radiographic resolution (CRR), with higher rates among those treated with DOACs (96%) than among those treated with warfarin (55%) or enoxaparin (77%), the researchers report in Inflammatory Bowel Diseases.

DOACs were also associated with higher rates of recanalization (7/7), compared with warfarin (4/8) and enoxaparin (3/5).

In multivariable analyses, the type of anticoagulant was the only factor significantly associated with CRR, with DOACs being associated with a 4.04-fold greater chance of CRR compared with warfarin. There was no particular factor associated with recanalization.

None of the patients who received DOACs and none of the patients who achieved CRR went on to develop systemic portal hypertension, but two enoxaparin-treated patients and one warfarin-treated patient who failed to achieve CRR did.

Two of the 45 patients who achieved CRR experienced recurrent PVT, both of whom had discontinued anticoagulation before recurrence.

Major bleeding occurred in four patients, three of whom were receiving warfarin and one of whom was receiving enoxaparin at the time.

"Very few patients in this study were found to have underlying thrombophilias, and thrombophilia testing is likely not required in most such patients (IBD itself is a sufficiently thrombophilic state to provoke PVT without the presence of concurrent hematologic abnormalities)," Dr. Naymagon said.

"I would caution that this study was retrospective and included relatively few patients (as PVT related to IBD is not particularly common)," he said. "Thus the study's conclusions should be taken with a grain of salt. Additional such studies would be helpful in confirming these findings."

SOURCE: Inflammatory Bowel Diseases, online March 18, 2020.