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Ha NB, Regal RE. Anticoagulation in Patients With Cirrhosis: Caught Between a Rock-Liver and a Hard Place. Ann Pharmacother 2016; 50:402-9. [PMID: 26861989 DOI: 10.1177/1060028016631760] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Nghi B Ha
- University of Michigan Health System, Ann Arbor, MI, USA University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
| | - Randolph E Regal
- University of Michigan Health System, Ann Arbor, MI, USA University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
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Wang Z, Jiang MS, Zhang HL, Weng NN, Luo XF, Li X, Yang L. Is Post-TIPS Anticoagulation Therapy Necessary in Patients with Cirrhosis and Portal Vein Thrombosis? A Randomized Controlled Trial. Radiology 2015; 279:943-51. [PMID: 26653681 DOI: 10.1148/radiol.2015150369] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Purpose To determine whether posttransjugular intrahepatic portosystemic shunt (TIPS) placement anticoagulation therapy could benefit patients with cirrhosis and portal vein thrombosis (PVT) from the perspective of a change in portal vein patency status and clinical outcomes. Materials and Methods The study was approved by the institutional review board, and informed consent was obtained from each patient. From October 2012 to February 2014, patients with cirrhosis and PVT who underwent TIPS placement were randomly assigned to the anticoagulation therapy or control group. All patients were followed at 1, 3, 6, and 12 months after the TIPS procedure. Outcome measures were a change of portal vein patency status and clinical measures including gastrointestinal rebleeding, shunt dysfunction, hepatic encephalopathy, and survival. Student t test, χ(2) test, Fisher exact test, Mann-Whitney U test, and logistical regression were applied where appropriate. Results A total of 64 patients were enrolled in the study, with 31 allocated to the anticoagulation group and 33 allocated to the control group. Overall, thrombi were improved in 61 patients (96.8%) after the procedure. PVT recanalization (ie, complete disappearance; reconstruction of cavernous transformation) was achieved in 26 patients (83.9%) in the anticoagulation therapy group and in 23 (71.8%) patients in tthe control group (P = .252). The presence of a superior mesenteric vein thrombus may help predict recanalization failure (unadjusted relative risk = 0.243; 95% confidence interval: 0.070, 0.843; P = .026). Clinical outcomes were also similar between the two groups. Conclusion Anticoagulation therapy may not be necessary in certain patients with PVT because TIPS placement alone can achieve a high persistent recanalization rate. (©) RSNA, 2015.
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Affiliation(s)
- Zhu Wang
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Ming-Shan Jiang
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Hai-Long Zhang
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Ning-Na Weng
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Xue-Feng Luo
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Xiao Li
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
| | - Li Yang
- From the Institution of Intervention Radiology (Z.W., X.F.L., X.L.) and Department of Gastroenterology (Z.W., M.S.J., H.L.Z., N.N.W., X.F.L., L.Y.), West China Hospital, Sichuan University, 37 Guoxue Lane, 610041 Chengdu, Sichuan, China
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Efird LM, Mishkin DS, Berlowitz DR, Ash AS, Hylek EM, Ozonoff A, Reisman JI, Zhao S, Jasuja GK, Rose AJ. Stratifying the Risks of Oral Anticoagulation in Patients With Liver Disease. Circ Cardiovasc Qual Outcomes 2014; 7:461-7. [DOI: 10.1161/circoutcomes.113.000817] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Lydia M. Efird
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Daniel S. Mishkin
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Dan R. Berlowitz
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Arlene S. Ash
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Elaine M. Hylek
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Al Ozonoff
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Joel I. Reisman
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Shibei Zhao
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Guneet K. Jasuja
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Adam J. Rose
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
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