ANTICOAGULATION IN PATIENTS WITH LIVER CIRRHOSIS: CLINICAL INDICATIONS, SAFETY, AND THERAPEUTIC SELECTION

Abstract

Introduction: Patients with liver cirrhosis exhibit a complex coagulopathy, placing them at simultaneous risk for bleeding and thrombosis. The contemporary understanding of “rebalanced hemostasis” challenges the outdated concept of spontaneous anticoagulation and reframes anticoagulation as a potential therapeutic strategy.

Purpose: To analyze the clinical indications, selection criteria, and risks associated with anticoagulant use in patients with liver cirrhosis, emphasizing the safety, efficacy, and practical application of anticoagulation in various clinical contexts.

Methods: A narrative literature review was conducted using PubMed, SciELO, Embase, and LILACS databases to identify studies published between 2018 and 2025. Search terms included anticoagulation, liver cirrhosis, portal vein thrombosis, and atrial fibrillation. International guidelines, systematic reviews, and clinically relevant observational studies were prioritized.

Results and Discussion: Anticoagulation appears safe and effective in compensated cirrhosis (Child–Pugh A/B), especially in cases of portal vein thrombosis (PVT) and atrial fibrillation. Anticoagulant choice should consider liver function, bleeding risk, renal status, and presence of esophageal varices. Direct oral anticoagulants (DOACs), such as apixaban and edoxaban, are preferred in CP A/B, while low molecular weight heparin (LMWH) or vitamin K antagonists (VKAs) are favored in more advanced cases. Endoscopic variceal prophylaxis should be performed before starting anticoagulation when indicated. A multidisciplinary approach and close clinical monitoring are essential. The lack of randomized trials in decompensated cirrhosis (CP B/C) remains a major limitation.

Final Considerations: When appropriately indicated and monitored, anticoagulation can improve clinical outcomes in cirrhotic patients. Future research must focus on randomized clinical trials and context-adapted protocols, especially within public health systems such as Brazil’s SUS and in vulnerable populations.