From the Guidelines
Eliquis (apixaban) should be used with caution in patients with cirrhosis and elevated MELD scores, with a preference for avoiding its use in those with Child-Pugh class C or MELD scores above 15-18, as suggested by the 2021 European Heart Rhythm Association Practical Guide and the 2023 American College of Cardiology/American Heart Association/American College of Chest Physicians/Heart Rhythm Society Guidelines 1. When considering the use of Eliquis in patients with cirrhosis, it is essential to weigh the risks and benefits, taking into account the patient's individual bleeding and thrombotic risks.
- For patients with compensated cirrhosis (Child-Pugh A), standard dosing may be appropriate,
- while those with Child-Pugh B may require dose reduction, though no official dosing guidelines exist 1. The liver metabolizes approximately 75% of apixaban, so impaired hepatic function leads to drug accumulation and increased bleeding risk. Alternative anticoagulation strategies like low molecular weight heparin or warfarin with close INR monitoring may be safer options for patients with advanced liver disease, as seen in studies such as Steensig et al., 2022 1, which reported a composite bleeding risk. Any anticoagulation decision should involve hepatology consultation and careful assessment of individual bleeding and thrombotic risks, with regular monitoring for complications, considering the complex coagulopathy present in patients with cirrhosis, which includes both increased bleeding and clotting risks 1. Laboratory monitoring is unreliable in these patients as liver dysfunction affects both the metabolism of apixaban and the coagulation tests used to monitor anticoagulation, highlighting the need for careful clinical judgment in managing anticoagulation in this population. Recent studies, such as Ayoub et al., 2023 1, have provided insights into the efficacy and safety of anticoagulation in patients with atrial fibrillation and cirrhosis, further guiding clinical decision-making. Ultimately, the decision to use Eliquis in patients with cirrhosis and elevated MELD scores must be made on a case-by-case basis, prioritizing the minimization of morbidity, mortality, and optimization of quality of life.
From the FDA Drug Label
Because patients with moderate hepatic impairment (Child-Pugh class B) may have intrinsic coagulation abnormalities and there is limited clinical experience with apixaban in these patients, dosing recommendations cannot be provided [see Clinical Pharmacology (12. 2)]. Apixaban is not recommended in patients with severe hepatic impairment (Child-Pugh class C) [see Clinical Pharmacology (12.2)].
The use of Eliquis (apixaban) in patients with cirrhosis and elevated Model for End-Stage Liver Disease (MELD) scores requires careful consideration.
- Hepatic Impairment: No dose adjustment is required in patients with mild hepatic impairment (Child-Pugh class A).
- Moderate Hepatic Impairment: Dosing recommendations cannot be provided for patients with moderate hepatic impairment (Child-Pugh class B) due to limited clinical experience and potential intrinsic coagulation abnormalities.
- Severe Hepatic Impairment: Apixaban is not recommended in patients with severe hepatic impairment (Child-Pugh class C). There is no direct information on the use of apixaban in patients with elevated MELD scores. 2 2
From the Research
Considerations for Using Eliquis in Patients with Cirrhosis and Elevated MELD Scores
- The use of Eliquis (apixaban) in patients with cirrhosis and elevated Model for End-Stage Liver Disease (MELD) scores requires careful consideration due to the potential risks of bleeding and thrombotic events 3, 4.
- A study published in Cureus found that the use of direct oral anticoagulants (DOACs), including apixaban, may be possible in patients with advanced cirrhosis, but further studies are needed to evaluate their safety and efficacy 3.
- Another study published in Revista medico-chirurgicala a Societatii de Medici si Naturalisti din Iasi found that low serum albumin and high MELD scores were independently predictive of thrombotic events in patients with liver cirrhosis 4.
- A review article published in Alimentary pharmacology & therapeutics noted that traditional anticoagulation is safe for all Child-Pugh classes, while newer DOACs are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment 5.
- The management of anticoagulation for portal vein thrombosis in individuals with cirrhosis is challenging due to coagulation abnormalities and the increased risk of bleeding, especially from gastrointestinal tract caused by portal hypertension 6.
- A study published in Liver international found that prophylactic anticoagulation for venous thromboembolism in hospitalized cirrhosis patients is not associated with high rates of gastrointestinal bleeding 7.
Key Factors to Consider
- MELD score: A high MELD score (>13) is associated with an increased risk of thrombotic events in patients with liver cirrhosis 4.
- Child-Pugh classification: The use of DOACs is mostly safe in Child-Pugh class A/B, but contraindicated in severe hepatic impairment 5.
- Serum albumin: Low serum albumin is associated with an increased risk of thrombotic events in patients with liver cirrhosis 4.
- Bleeding risk: The use of anticoagulants in patients with cirrhosis requires careful consideration of the bleeding risk, especially from gastrointestinal tract caused by portal hypertension 6.
Monitoring and Management
- Close monitoring of patients with cirrhosis and elevated MELD scores who are receiving Eliquis is necessary to minimize the risk of bleeding and thrombotic events 3, 4.
- Regular assessment of liver function, renal function, and coagulation parameters is essential to adjust the dose of Eliquis and minimize the risk of adverse events 5.
- The use of Eliquis in patients with cirrhosis and elevated MELD scores should be individualized and based on a careful assessment of the benefits and risks of anticoagulation therapy 3, 4.