TO THE EDITOR:

Patients with end-stage chronic liver disease (ie, cirrhosis) acquire multiple and complex alterations in their hemostatic system. Recent insights in the hemostatic changes in patients with cirrhosis have indicated a balanced, but unstable hemostatic system in these patients with a risk for both bleeding and thrombotic complications including venous thromboembolism and portal vein thrombosis.1,2  Prevention and treatment of thrombotic events are a challenge because of a frequently prolonged baseline international normalized ratio and substantially decreased levels of antithrombin, impeding correct dosing and monitoring of vitamin K antagonists and heparins, respectively.3,4  There is very limited clinical experience with the new-generation direct oral anticoagulants (DOACs) in patients with cirrhosis because these patients were excluded from all clinical trials with these new agents. However, DOACs have potential advantages over vitamin K antagonists and heparins, such as the oral route...

REFERENCES

1.
Lisman
T
,
Porte
R
.
Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences
.
Blood
.
2010
;
116
(
6
):
878
-
885
.
2.
Tripodi
A
,
Mannucci
P
.
The coagulopathy of chronic liver disease
.
N Engl J Med
.
2011
;
365
(
2
):
147
-
156
.
3.
Potze
W
,
Arshad
F
,
Adelmeijer
J
, et al
.
Routine coagulation assays underestimate levels of antithrombin-dependent drugs but not of direct anticoagulant drugs in plasma from patients with cirrhosis
.
Br J Haematol
.
2013
;
163
(
5
):
666
-
673
.
4.
Lisman
T
,
Kamphuisen
P
,
Northup
P
,
Porte
R
.
Established and new-generation antithrombotic drugs in patients with cirrhosis - possibilities and caveats
.
J Hepatol
.
2013
;
59
(
2
):
358
-
366
.
5.
Weinberg
E
,
Palecki
J
,
Reddy
K
.
Direct-acting oral anticoagulants (DOACs) in cirrhosis and cirrhosis-associated portal vein thrombosis
.
Semin Liver Dis
.
2019
;
39
(
2
):
195
-
208
.
6.
Hoolwerf
E
,
Kraaijpoel
N
,
Büller
H
,
van Es
N
.
Direct oral anticoagulants in patients with liver cirrhosis: a systematic review
.
Thromb Res
.
2018
;
170
(
July
):
102
-
108
.
7.
Lee
H
,
Chan
Y
,
Chang
S
, et al
.
Effectiveness and safety of non-vitamin K antagonist oral anticoagulant and warfarin in cirrhotic patients with nonvalvular atrial fibrillation
.
J Am Heart Assoc
.
2019
;
8
(
5
):
e011112
.
8.
Intagliata
N
,
Maitland
H
,
Caldwell
S
.
Direct oral anticoagulants in cirrhosis
.
Curr Treat Options Gastroenterol
.
2016
;
14
(
2
):
247
-
256
.
9.
Bos
S
,
van den Boom
B
,
Kamphuisen
P
, et al
.
Haemostatic profiles are similar across all aetiologies of cirrhosis
.
Thromb Haemost
.
2019
;
119
(
2
):
246
-
253
.
10.
Potze
W
,
Arshad
F
,
Adelmeijer
J
, et al
.
Differential in vitro inhibition of thrombin generation by anticoagulant drugs in plasma from patients with cirrhosis
.
PLoS One
.
2014
;
9
(
2
):
e88390
.
11.
Potze
W
,
Adelmeijer
J
,
Lisman
T
.
Decreased in vitro anticoagulant potency of Rivaroxaban and Apixaban in plasma from patients with cirrhosis
.
Hepatology
.
2015
;
61
(
4
):
1435
-
1436
.
12.
Weitz
J
,
Connolly
S
,
Patel
I
, et al
.
Randomised, parallel-group, multicentre, multinational phase 2 study comparing edoxaban, an oral factor Xa inhibitor, with warfarin for stroke prevention in patients with atrial fibrillation
.
Thromb Haemost
.
2010
;
104
(
3
):
633
-
641
.
13.
Lebreton
A
,
Sinegre
T
,
Pereira
B
,
Lamblin
G
,
Duron
C
,
Abergel
A
.
Plasma hypercoagulability in the presence of thrombomodulin but not of activated protein C in patients with cirrhosis
.
J Gastroenterol Hepatol
.
2017
;
32
(
4
):
916
-
924
.
You do not currently have access to this content.

Sign in via your Institution

Sign In