Ma Jiayi, Chalasani Naga P, Schwantes-An Linus, Björnsson Einar Stefán
Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA.
Indiana University School of Medicine, Medical & Molecular Genetics, Indianapolis, Indiana, USA.
Aliment Pharmacol Ther. 2023 Jan;57(1):52-71. doi: 10.1111/apt.17297. Epub 2022 Nov 14.
Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.
长期以来，肝硬化患者一直被认为存在凝血功能障碍。然而，近年来这种观念已经改变，目前，肝硬化被认为是一种血栓前状态。由于与心脏疾病密切相关的非酒精性脂肪性肝炎导致的肝硬化发病率不断上升，肝硬化患者越来越需要使用抗凝剂和抗血小板药物进行治疗。然而，这些药物在肝硬化患者中可能导致灾难性和危及生命的出血，这使得人们在肝硬化患者中使用这些药物时犹豫不决。总体而言，传统抗凝治疗对所有Child-Pugh分级的患者都是安全的，而新型直接口服抗凝剂（DOACs）在Child-Pugh A/B级患者中大多是安全的，在严重肝功能损害患者中禁用。就不同适应症而言，迄今为止发表的数据表明，对于患有静脉血栓栓塞、心房颤动和门静脉血栓形成的肝硬化患者，抗凝治疗总体上是安全的，并且不会增加静脉曲张出血的风险。此外，DOACs的安全性似乎与传统抗凝剂相似。最后，大多数研究表明，抗血小板药物在肝硬化患者中使用也是安全的，尽管在严重肝功能损害患者中大多禁用。对于抗凝剂和抗血小板药物，严重血小板减少都是使用它们的相对禁忌症。需要更多的前瞻性试验和大型队列研究来加深我们对DOACs和抗血小板药物在晚期肝硬化患者中的安全性及细微差别的理解。
