Anticoagulation in cirrhosis

Patients with cirrhosis are at increased risk of atrial fibrillation and venous thromboembolism, for which anticoagulation is standard of care. Historical misunderstanding of the complex haemostatic changes which occur in cirrhosis, along with the increased baseline risk of bleeding, has contributed to concerns regarding anticoagulation in this patient group. It is now accepted that haemostasis in patients with cirrhosis is rebalanced and that the risk of bleeding is predominantly mediated by portal hypertension. However, patients with cirrhosis were excluded from seminal randomised controlled trials of direct oral anticoagulants, resulting in low-quality evidence to inform best practice in this patient group. Cohort studies predominantly in atrial fibrillation suggest anticoagulation reduces stroke risk and improves survival in patients with cirrhosis. Similarly, anticoagulation for portal vein thrombosis reduces thrombosis progression, promotes recanalisation and may improve survival. Additionally, small, randomised studies suggest anticoagulation has a potential role in reducing the risk of hepatic decompensation and liver disease progression. In this review, current knowledge of the efficacy and safety of anticoagulation in patients with cirrhosis is presented. Concerns related to portal hypertension, thrombocytopenia and liver transplantation are discussed, with an approach to the initiation and management of anticoagulation in atrial fibrillation and venous thromboembolism provided.