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Prospective study of oral anticoagulants and risk of liver injury in patients with atrial fibrillation
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  • Published on:
    Liver injury with direct-acting anticoagulants: has the fog cleared?
    • Emanuel Raschi, Assistant Professor Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences
    • Other Contributors:
      • Fabrizio De Ponti, Full Professor

    To the Editor,
    The timely retrospective US cohort study by Alonso et al.1 assessed the risk of hospitalisations for liver injury after initiation of oral anticoagulation in patients with non-valvular atrial fibrillation, an unresolved safety issue so far.
    This study has key merits. First, it demonstrates the importance of conducting analytical research following safety signals emerging from spontaneous reporting systems2, to confirm or refute the drug-related hypothesis; this allows actual risk assessment and avoids unnecessary alarm, sometimes generated by pharmacovigilance analyses which do not recognize the limits of detected signals.
    Second, it provides a significant contribution to the debate on targeted patients’ selection when prescribing DOACs. In fact, the authors found that hospitalization rates for liver injury were lower among DOAC initiators as compared to patients starting warfarin, with rivaroxaban and dabigatran associated with highest and lowest risk, respectively. They conclude that “dabigatran may be considered a safer option” in patients susceptible of liver complications. In this vulnerable population, our proposal when initiating DOAC administration is to early monitor hepatic enzymes (i.e., within the first month of therapy) and, subsequently, on a yearly basis, especially for rivaroxaban users.3
    Although this study contributes to allay concern on the hepatotoxicity potential of DOACs, a residual aspect deserves attention. The...

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    Conflict of Interest:
    None declared.