Anticoagulation in cirrhosis: Best practices


Background: Alterations to the coagulation cascade put cirrhotic patients at higher risk for bleeding and thrombotic complications.

Study design: Expert review.

Setting: Literature review.

Synopsis: The authors provide 12 best practice recommendations, including use blood products sparingly in the absence of active bleeding out of concern for raising portal pressures; low-risk paracentesis, thoracentesis, and upper endoscopy do not require routine correction of thrombocytopenia or coagulopathy; for active bleeding or high-risk procedures, correct hematocrit to above 25%, platelets to more than 50,000, and fibrinogen to above 120 mg/dL; the risk of thrombosis, including venous thromboembolism and portal vein thrombosis, is high in these patients despite elevated INR values.

As such, pharmacologic VTE prophylaxis is often underutilized in patients admitted with cirrhosis; for patients requiring therapeutic anticoagulation, direct oral anticoagulants are safe in stable patients with mild cirrhosis, but should be avoided in Child-Pugh B and C patients.

Bottom line: Cirrhotic patients do not require routine correction of coagulopathy prior to low-risk procedures.

Citation: O’Leary JG et al. AGA Clinical Practice Update: Coagulation in cirrhosis. Gastroenterology. 2019. doi: 10.1053/j.gastro.2019.03.070.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

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