Anticoagulation in patients with cirrhosis

EASL 2022

In patients with liver disease who do not have cirrhosis, and those with Child–Pugh class A cirrhosis, anticoagulant therapy is generally the same as for patients who do not have liver disease; see the Cardiovascular guidelines for details.

In patients with decompensated cirrhosis, the choice of anticoagulants is limited.

• Unfractionated and low-molecular weight heparin can be used.
• Warfarin should not be used as it is difficult to interpret the international normalised ratio (INR) in the setting of liver synthetic dysfunction.
• Direct-acting oral anticoagulants (DOACs) (apixaban, dabigatran, rivaroxaban) should not be used in Child–Pugh class C cirrhosis. In Child–Pugh class B cirrhosis, apixaban and dabigatran can be used with caution under specialist supervision. Rivaroxaban is not recommended in Child–Pugh class B cirrhosis because safety data are lacking.

For general information about anticoagulant therapy, including management of bleeding and overanticoagulation, see the Cardiovascular guidelines.