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Direct Oral Anticoagulants in Cirrhosis

  • Liver (J Bajaj, Section Editor)
  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

The risk of thrombosis in patients with chronic liver disease is increasingly recognized. As patients with cirrhosis develop indications for anticoagulation therapy (e.g., venous thromboembolism, portal vein thrombosis, or atrial fibrillation), providers are left to make difficult decisions when selecting therapeutics with little evidence to rely on. Current practice supports the use of low molecular weight heparin or vitamin K antagonists in select patients with cirrhosis requiring anticoagulation. While traditional anticoagulants may be safe and effective in select patients with compensated cirrhosis, the use of direct oral anticoagulants (DOAC) is more controversial. DOAC are desirable as they do not require routine monitoring and can be taken orally. Unfortunately, patients with chronic liver disease were excluded from clinical trials that demonstrated efficacy and safety when compared to traditional anticoagulation. Data are now emerging that support the use of DOAC in well-compensated cirrhosis patients. However, further study is needed with all (traditional and DOAC) anticoagulation medications in patients with cirrhosis to better ensure safety and further understand pharmacologic properties in this challenging population.

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Abbreviations

DOAC:

Direct oral anticoagulant

VKA:

Vitamin K antagonist

LMWH:

Low molecular weight heparin

VTE:

Venous thromboembolism

PVT:

Portal vein thrombosis

INR:

International normalized ratio

GI:

Gastrointestinal

P-gp:

P-glycoprotein

MELD:

Model for end staged liver disease

CTP:

Childs-Turcotte-Pugh

ETP:

Endogenous thrombin potential

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Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Center for Coagulation in Liver Disease, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, USA

    Nicolas M. Intagliata MD & Stephen H. Caldwell MD

  2. Division of Hematology, University of Virginia Medical Center, Charlottesville, VA, USA

    Hillary Maitland MD

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  1. Nicolas M. Intagliata MD
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  2. Hillary Maitland MD
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  3. Stephen H. Caldwell MD
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Correspondence to Nicolas M. Intagliata MD.

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Hillary Maitland declares no conflict of interest.

Nicolas M. Intagliata has received personal fees from Vital Therapies.

Stephen H. Caldwell has received personal fees from Vital Therapies.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Liver

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Intagliata, N.M., Maitland, H. & Caldwell, S.H. Direct Oral Anticoagulants in Cirrhosis. Curr Treat Options Gastro 14, 247–256 (2016). https://doi.org/10.1007/s11938-016-0092-0

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