title: Direct Oral Anticoagulants in Cirrhosis.
abstract: 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.
authors.affiliation: Division of Gastroenterology and Hepatology, Center for Coagulation in Liver Disease, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, USA. intagliata@virginia.edu.
authors.forename: Nicolas M
authors.initials: NM
authors.lastname: Intagliata
authors.affiliation: Division of Hematology, University of Virginia Medical Center, Charlottesville, VA, USA.
authors.forename: Hillary
authors.initials: H
authors.lastname: Maitland
authors.affiliation: Division of Gastroenterology and Hepatology, Center for Coagulation in Liver Disease, University of Virginia Medical Center, PO Box 800708, Charlottesville, VA, USA.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Caldwell
keywords: Bleeding; Direct oral anticoagulants; Factor Xa; Heparin; Portal vein; Thrombin; Thrombosis; Warfarin