Work

Activated charcoal neutralization restores accurate Model for End-Stage Liver Disease and Child-Pugh scores in patients with cirrhosis on direct oral anticoagulant therapy

Year: 2025

Type: article

Abstract: Background: The use of direct oral anticoagulants (DOACs) is increasingly common, including among patients with cirrhosis. These treatments interfere with coagulation tests, altering the Model for End-Stage Liver Disease (MELD) and Child-Pugh scores, which are critical for assessing disease severity and prioritizing patients on liver transplant waiting lists. Objective: To evaluate the impact of rivaroxaban and apixaban on MELD and Child-Pugh scores and assess charcoal-based neutralization. Methods: impact of rivaroxaban and apixaban, at concentrations corresponding to peak plasma levels (300 ng/mL and 150 ng/mL, respectively), on the calculation of these scores. A total of 35 plasma samples from patients with cirrhosis (prothrombin level [PT%]: 13%-104%) were analyzed. INR (international normalized ratio) and PT% were measured before supplementation, after supplementation with rivaroxaban or apixaban, and after DOAC neutralization using activated charcoal (DOAC-Stop). Results: Rivaroxaban and apixaban supplementation led to an increase in INR (median: 2.81 and 0.70, respectively), resulting in a median overestimation of the MELD score by 12 and 4 points, respectively. PT% was underestimated (median: 70% for rivaroxaban and 48% for apixaban), which impacted the Child-Pugh classification in 4 and 2 patients, respectively. Neutralization of rivaroxaban and apixaban with activated charcoal resulted in INR and PT% values that were comparable to baseline measurements and remained within the analytical variability of the method. Conclusion: These findings highlight the importance of identifying patients on DOAC therapy and implementing neutralization techniques to avoid overestimating disease severity. DOAC-Stop effectively eliminates rivaroxaban- and apixaban-related interference, even in this specific population of patients with cirrhosis who sometimes have profoundly decreased PT% values. Failure to account for DOAC interference could lead to mismanagement and errors in prioritizing patients for liver transplantation.

Source: Research and Practice in Thrombosis and Haemostasis

DOI: 10.1016/j.rpth.2025.103289