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DOACs in cirrhosis: Progress, pitfalls, and the path forward.
Alexa Loncharich1, Kelsey Bria1, Amber Afzal1
1Department of Medicine, Division of Hematology, Washington University in St Louis, St. Louis, MO, USA.
Thrombosis Research
|May 29, 2026
Summary
Direct oral anticoagulants (DOACs) are increasingly used in cirrhosis patients with Child-Pugh A or B. Evidence suggests comparable effectiveness to vitamin K antagonists (VKAs) with potentially reduced bleeding risks.
Area of Science:
- Hepatology
- Pharmacology
- Cardiology
Background:
- Direct oral anticoagulants (DOACs) were historically contraindicated in cirrhosis due to safety concerns.
- Limited data existed on DOAC efficacy and safety in patients with liver disease.
Purpose of the Study:
- To evaluate the current evidence on DOAC use in patients with cirrhosis.
- To compare DOACs with vitamin K antagonists (VKAs) for various thromboembolic conditions.
Main Methods:
- Review of retrospective cohorts, meta-analyses, and prospective studies.
- Analysis of pharmacokinetic data in Child-Pugh A, B, and C cirrhosis.
- Comparison of DOACs versus VKAs for atrial fibrillation, splanchnic vein thrombosis, and venous thromboembolism.
Main Results:
- DOACs show predictable pharmacokinetics in Child-Pugh A/B cirrhosis.
- DOACs are effective for atrial fibrillation (AF) in Child-Pugh A/B cirrhosis, comparable to VKAs, with potentially lower bleeding.
- DOACs improve recanalization in splanchnic vein thrombosis (SVT) versus VKAs, with similar or lower bleeding risk.
Conclusions:
- DOACs are increasingly supported for AF in Child-Pugh A/B cirrhosis.
- DOACs demonstrate benefits in SVT management.
- Further research is needed for VTE and primary prophylaxis in cirrhosis.
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