Anticoagulation in Patients With Cirrhosis: Caught Between a Rock-Liver and a Hard Place

Ann Pharmacother. 2016 May;50(5):402-9. doi: 10.1177/1060028016631760. Epub 2016 Feb 9.


Objective: To review current literature for anticoagulation in patients with cirrhosis and provide a summary of the effects of cirrhosis on the coagulation cascade, therapeutic monitoring through interpretation of antifactor Xa (anti-Xa), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) as well as current prophylaxis and treatment recommendations in cirrhotic patients.

Methods: A systematic electronic literature search was conducted in PubMed using the key termsanticoagulation, warfarin, low-molecular-weight heparin(LMWH),unfractionated heparin(UFH),target-specific oral anticoagulants, deep-vein thrombosis(DVT),pulmonary embolism(PE),portal vein thrombosis(PVT),venous thromboembolism, anti-Xa, activated partial thromboplastin time, anticoagulation therapeutic monitoring, coagulopathy, coagulation cascade, chronic liver disease, cirrhosis, anddecompensated liver disease

Study selection: Studies written in the English language from January 2000 to December 2015 were considered for this review article. All search results were reviewed, and the relevance of each article was determined by authors independently.

Conclusions: Patients with cirrhosis are at higher risk for both bleeding and thrombosis-related complications. Cirrhosis affects production of both procoagulant and anticoagulant factors, thus resulting in increased INR and aPTT levels and decreased anti-Xa levels. LMWH is the treatment of choice for the prevention and treatment of DVT/PE/PVT in patients with cirrhosis, and monitoring with anti-Xa levels for dose adjustment is not recommended. UFH is an alternative in cirrhotic patients for shorter-term use and in cases of severe renal dysfunction and/or hemodynamic instability. Cirrhotic patients on anticoagulation therapy should be monitored closely for signs and symptoms of bleeding and thrombosis.

Keywords: DVT; LMWH; PE; PT/INR; PVT; UHF; VTE; aPTT; anti-Xa; anticoagulation; cirrhosis.

Publication types

  • Review

MeSH terms

  • Anticoagulants / therapeutic use*
  • Hemorrhage / chemically induced
  • Heparin / therapeutic use
  • Humans
  • International Normalized Ratio
  • Liver Cirrhosis / blood*
  • Partial Thromboplastin Time
  • Pulmonary Embolism / prevention & control
  • Venous Thromboembolism / prevention & control
  • Venous Thrombosis / prevention & control
  • Warfarin / therapeutic use


  • Anticoagulants
  • Warfarin
  • Heparin