Beyond the class effect: Rethinking anticoagulation in liver disease

The use of direct oral anticoagulants (DOACs) has transformed hepatology. Initially introduced as an alternative to vitamin K antagonists and low-molecular-weight heparin for portal vein thrombosis (PVT), DOACs are now increasingly used across the spectrum of vascular liver diseases (VLD) and cirrhosis. Yet, current hepatology guidelines continue to treat DOACs as a homogeneous therapeutic class, assuming that differences between individual molecules have limited clinical relevance (Fig. 1).