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

## TL;DR

Activated charcoal can correct the effects of anticoagulants on liver disease scores in cirrhosis patients, ensuring accurate test results.

## Contribution

Activated charcoal neutralization effectively restores accurate coagulation test results in cirrhosis patients on DOAC therapy.

## Key findings

- Rivaroxaban and apixaban overestimated MELD scores by 12 and 4 points, respectively.
- Activated charcoal neutralization returned INR and PT% values to baseline levels.
- DOAC interference can lead to mismanagement of liver disease severity and transplant prioritization.

## Abstract

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.

To evaluate the impact of rivaroxaban and apixaban on MELD and Child-Pugh scores and assess charcoal-based neutralization.

We investigated the in vitro 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).

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.

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.

•Direct oral anticoagulants interfere with hemostasis tests, even in liver disease.•Coagulation tests were performed on cirrhotic plasma after in vitro rivaroxaban/apixaban supplementation.•Rivaroxaban and apixaban distorted MELD and Child-Pugh scores, risking liver function measurement errors.•Activated charcoal neutralized rivaroxaban/apixaban, enabling accurate and reliable test results.

Direct oral anticoagulants interfere with hemostasis tests, even in liver disease.

Coagulation tests were performed on cirrhotic plasma after in vitro rivaroxaban/apixaban supplementation.

Rivaroxaban and apixaban distorted MELD and Child-Pugh scores, risking liver function measurement errors.

Activated charcoal neutralized rivaroxaban/apixaban, enabling accurate and reliable test results.