Safety of using anticoagulants in patients with cirrhosis

Using anticoagulation in many cirrhosis patients doesn't seem to be riskier than in those without cirrhosis....

As a hospital pharmacist, you'll see anticoagulants used more often to treat thrombosis in patients with cirrhosis. We're used to thinking of these patients as having an increased bleeding risk due to impaired clotting factor production and thrombocytopenia.

But don't consider them "auto-anticoagulated".. Decreased protein C and other prothrombotic changes typically rebalance bleeding risk. In fact, cirrhosis is associated with increased venous thromboembolism (VTE) risk and increased VTE-related mortality. Work with GI physician or liver specialist when treating VTE in cirrhosis, especially for Child-Pugh C, since there's less evidence. Plus some portal vein thromboses may not require anticoagulation.

Using anticoagulation in many cirrhosis patients doesn't seem to be riskier than in those without cirrhosis. But when patients also have esophageal varices, bleeding risk with anticoagulation seems to go up. To minimize this risk, expect to see treatments, such as variceal banding if necessary or possibly nonselective beta-blockers (propranolol, nadolol) to reduce portal pressure and prevent bleeding.

Anticipate use of low-molecular-weight heparin (LMWH) to treat VTE, with bridging to warfarin unless the INR is elevated. Some experts allow warfarin when baseline INRs are elevated, but still below 1.7. Or a direct oral anticoagulant (DOAC) may be chosen in Child-Pugh A cirrhosis or possibly Child-Pugh B. Limited evidence suggests bleeding risk is similar to using warfarin or LMWH. Ensure close follow-up postdischarge for regular monitoring.

References

O'Leary JG, Greenberg CS, Patton HM, Caldwell SH. AGA Clinical Practice Update: Coagulation in Cirrhosis. Gastroenterology. 2019 Jul;157(1):34-43.e1. Available at: https://pubmed.ncbi.nlm.nih.gov/30986390

Qamar A, Vaduganathan M, Greenberger NJ, Giugliano RP. Oral Anticoagulation in Patients With Liver Disease. J Am Coll Cardiol. 2018 May 15;71(19):2162-2175. Available at: https://pubmed.ncbi.nlm.nih.gov/29747837

Steuber TD, Howard ML, Nisly SA. Direct Oral Anticoagulants in Chronic Liver Disease. Ann Pharmacother. 2019 Oct;53(10):1042-1049. Available at: https://pubmed.ncbi.nlm.nih.gov/30947523