Oral anticoagulation therapy in the setting of liver disease

Anticoagulation in patients with liver disease presents a complex clinical challenge due to complex changes in hemostasis seen in hepatic dysfunction. Historically underrepresented in clinical trials, anticoagulation in this population remains a topic of uncertainty. This review examines the current evidence regarding efficacy and safety of anticoagulation in liver disease. Comparative study between anticoagulants is summarized, with a focus on direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs). Key factors influencing outcomes are discussed, including liver disease severity, timing of therapy initiation, thrombus characteristics, and pre-anticoagulation variceal management. Current evidence suggests that DOAC therapy is at least as effective as VKA for stroke prevention in atrial fibrillation (AF) and treatment of portal venous thrombosis (PVT) in patients with liver disease, possibly with a superior safety profile. Guidelines support DOAC use in Child-Pugh class A cirrhosis and cautious use in Child-Pugh B. There is a lack of controlled trial data, especially in patients with moderate to severe liver disease. Observational studies often report low bleeding rates with anticoagulation, possibly due to selection bias and pre-anticoagulation variceal treatment. Future research should prioritize controlled trials and explore DOAC use in moderate to severe liver disease.