From the Guidelines
DVT prophylaxis is generally indicated in hospitalized patients with cirrhosis, as the benefits of preventing venous thromboembolism (VTE) outweigh the risks of bleeding, according to the most recent and highest quality study 1.
Key Points
- The use of prophylactic anticoagulation in hospitalized patients with cirrhosis reduces the risk of symptomatic deep vein thrombosis (DVT) 1.
- Low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily or unfractionated heparin 5000 units subcutaneously every 8-12 hours should be used for prophylaxis during hospitalization, even in the presence of coagulopathy.
- Patients with cirrhosis have a rebalanced hemostatic system and are at increased risk for VTE due to portal hypertension, immobility during hospitalization, and systemic inflammation.
- For patients with low platelet counts (<50,000/μL) or active bleeding, individualized risk assessment is necessary, and mechanical prophylaxis with sequential compression devices should be considered when pharmacological prophylaxis is contraindicated.
- The most recent study 1 suggests that direct oral anticoagulants (DOACs) may be a safe and effective option for DVT prophylaxis in patients with cirrhosis, with reduced risks of major bleeding and intracranial hemorrhage compared to traditional anticoagulant drugs.
Considerations
- The occurrence of DVT/PE in patients with cirrhosis is associated with prolonged hospital stay and has a clear-cut impact on prognosis, with significantly increased mortality 1.
- Thromboprophylaxis would appear a sensible option to offer to patients with cirrhosis and risk factors for DVT/PE, such as prolonged hospitalization and immobilization, surgery, and male sex 1.
- However, the use of thromboprophylaxis for VTE has not been extensively used in patients with cirrhosis due to the perceived increased risk of bleeding associated with the coagulopathy of cirrhosis.
From the FDA Drug Label
Low-Dose Prophylaxis of Postoperative Thromboembolism A number of well-controlled clinical trials have demonstrated that low-dose heparin prophylaxis, given just prior to and after surgery, will reduce the incidence of postoperative deep vein thrombosis in the legs Patients with bleeding disorders and those having neurosurgery, spinal anesthesia, eye surgery or potentially sanguineous operations should be excluded, as well as patients receiving oral anticoagulants or platelet-active drugs
The FDA drug label does not answer the question about DVT prophylaxis in cirrhosis. Cirrhosis is not mentioned in the provided drug labels as an indication for DVT prophylaxis with heparin. Therefore, no conclusion can be drawn about the use of heparin for DVT prophylaxis in patients with cirrhosis based on the provided information 2, 2.
From the Research
DVT Prophylaxis in Cirrhosis
- DVT prophylaxis is indicated in patients with cirrhosis, as they are at a higher risk for both bleeding and thrombosis-related complications 3, 4.
- Low-molecular-weight heparin (LMWH) is the treatment of choice for the prevention and treatment of DVT/PE/PVT in patients with cirrhosis 3.
- LMWH appears to be relatively safe in patients with cirrhosis, but the risk of bleeding complications should be carefully considered, especially in patients with advanced liver disease or a history of variceal bleeding 4, 5, 6.
- The use of anti-Xa assays for monitoring LMWH therapy in cirrhotic patients may be limited due to decreased antifactor Xa activity and antithrombin-III levels in these patients 5.
- Prophylactic anticoagulation may be beneficial in patients with cirrhosis to mitigate the progression of fibrosis and reduce the risk of liver decompensation and mortality 7.
Risk Factors and Considerations
- Patients with cirrhosis have a higher incidence of unprovoked DVT and pulmonary embolism (PE) compared to the general population 4.
- Serum albumin level is independently associated with the occurrence of thrombosis in patients with cirrhosis 4.
- Liver resection can unbalance the hemostatic equilibrium towards a hypercoagulable state, increasing the risk of thrombotic complications 4.
- Advanced liver disease and a history of variceal bleeding are risk factors for bleeding complications in patients with cirrhosis receiving anticoagulation therapy 6.