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Evaluating the Use of Anticoagulants in Patients with Advanced Liver Disease

Although patients with cirrhosis seem to be at a higher risk of developing thrombotic disease, current clinical guidelines do not make any recommendations to physicians for the use of anti-coagulants as a prophylactic measure. Therefore, before any changes to clinical guidelines can be made, prospective studies are needed to examine whether patients with cirrhosis could benefit from prophylaxis, and if so, what an ideal drug regimen would look like. Until such studies are conducted, the benefits and disadvantages for each patient need to be assessed on a case-by-case basis, with the ultimate tough decision falling into the hands of the attending physician.
An additional wrench in the works is the issue of accurately assessing anticoagulation status in patients, a critical parameter to consider before administering anticoagulant drugs. Currently, the international normalized ratio (INR), a prothrombin time test, is utilized, where a high INR indicates slow clotting blood and a lower INR means the patient’s blood is clotting faster than normal. Current clinical guidelines support aiming for an INR of 2.0 or 3.0. However, no studies have been conducted to determine if this is a sound approach to monitoring patients with cirrhosis. Overall, more studies are needed to evaluate optimal dosing regimens, as mentioned previously, and to determine a more effective way to assess anticoagulation status.
To return to the original case study, prophylactic anticoagulation was not administered to the patient due to concerns about the risk of bleeding. It is natural to have such trepidations about the safety of such a measure and to question if anticoagulation therapy can be safely and effectively used in patients with cirrhosis without significantly heightening their risk of bleeding. Dr. Thursz and his colleagues concluded, “With careful screening and management of varices, there does not seem to a significantly increased risk of bleeding, implying that patients may be safely anticoagulated either in the setting of prophylaxis or therapeutic treatment.”
In summation, although evidence suggests that patients with advanced liver disease could stand to benefit from anticoagulation as a prophylactic measure, much research is still needed before clinical guidelines can make this recommendation. In the future, studies are needed to determine the ideal dosing regimens for anticoagulation therapy and an effective and accurate way to assess anticoagulation status. 
Feature Image Source: ScienceSource/Pasieka
Samar Mahmoud graduated from Drew University in 2011 with a BA in biochemistry and molecular biology. After two years of working in industry as a quality control technician for a blood bank, she went back to school and graduated from Montclair State University in 2016 with a MS in pharmaceutical biochemistry. She is currently pursuing her PhD in molecular and cellular biology at the University of Massachusetts at Amherst. 

  1. Khoury T, Ayman AR, Cohen J, Daher S, Shmuel C, Mizrahi M. The complex role of anticoagulation in cirrhosis: an updated review of where we are and where we are going. Digestion. 2016;93(2):149-159. doi:10.1159/000442877.
  2. Dhar A, Mullish BH, Thursz MR. Anticoagulation in chronic liver disease. J Hepatol. 2017; pii:S0168-8278(17)30010-30017. [Epub ahead of print] doi:10.1016/j.jhep.2017.01.006. 

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