From the Guidelines
DVT prophylaxis in cirrhosis should be administered using low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) in patients at risk, as recommended by the most recent guidelines. The choice of anticoagulant depends on the patient's Child-Pugh class, with LMWH being a reasonable option for all classes and DOACs being recommended for Child-Pugh class A and B patients 1.
Key Considerations
- Patients with cirrhosis are at risk of venous thromboembolism (VTE) despite their coagulopathy, and prophylaxis can reduce this risk 1.
- The efficacy of thromboprophylaxis in cirrhosis is unclear, but it has a reasonable safety profile 1.
- DOACs are not recommended for patients with Child-Pugh class C cirrhosis due to limited safety data 1.
- Regular monitoring of platelet counts and renal function is advisable during prophylaxis.
Recommended Approach
- Use pharmacological prophylaxis with LMWH, such as enoxaparin 40mg subcutaneously once daily, or unfractionated heparin 5000 units subcutaneously every 8-12 hours.
- For patients with severe thrombocytopenia (platelets <50,000/μL) or active bleeding, mechanical prophylaxis with sequential compression devices should be used instead.
- Prophylaxis should be continued throughout the hospital stay, and dose adjustment of LMWH may be necessary in patients with renal dysfunction 1.
From the FDA Drug Label
1.1 Prophylaxis of Deep Vein Thrombosis Fondaparinux sodium injection is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE): in patients undergoing hip fracture surgery, including extended prophylaxis; in patients undergoing hip replacement surgery; in patients undergoing knee replacement surgery; in patients undergoing abdominal surgery who are at risk for thromboembolic complications.
The FDA drug label does not answer the question regarding DVT prophylaxis in cirrhosis.
From the Research
DVT Prophylaxis in Cirrhosis
- Patients with cirrhosis are at higher risk for both bleeding and thrombosis-related complications, including deep-vein thrombosis (DVT) 2, 3.
- The use of low-molecular-weight heparin (LMWH) is recommended for the prevention and treatment of DVT in patients with cirrhosis, as it is considered relatively safe in this group of patients 2, 3, 4.
- Monitoring with anti-Xa levels for dose adjustment is not recommended for LMWH in cirrhotic patients 2.
- Unfractionated heparin (UFH) is an alternative in cirrhotic patients for shorter-term use and in cases of severe renal dysfunction and/or hemodynamic instability 2.
- Patients with cirrhosis on anticoagulation therapy should be monitored closely for signs and symptoms of bleeding and thrombosis 2, 5.
- The incidence of DVT in patients with cirrhosis ranges from 0.5% to 1.9%, similar to patients without comorbidities, but lower than patients with other chronic diseases 3.
- Serum albumin level was independently associated with the occurrence of thrombosis in patients with cirrhosis 3.
- Advanced liver disease and a history of variceal bleeding are risk factors for bleeding in patients with cirrhosis on anticoagulation therapy 5, 4.
- Direct oral anticoagulants (DOACs) may be considered for the treatment of portal vein thrombosis in patients with cirrhosis, but their safety and efficacy are not well-established in this population 6.