Evaluation of venous thromboembolism prophylaxis in patients with chronic liver disease

Abstract

BACKGROUND The incidence of venous thromboembolism (VTE) in chronic liver disease (CLD) patients has been reported to be 0.5% to 6.3%. Studies report the use of thromboprophylaxis in CLD patients as suboptimal, with at least 75% of patients receiving no prophylaxis. OBJECTIVE To describe the use of VTE prophylaxis in CLD patients. DESIGN A retrospective review. SETTING Tertiary‐care academic medical center. PATIENTS Inpatient admissions from August 2009 through July 2011 with CLD diagnosis. INTERVENTION None. MEASUREMENTS Initiation and type of thromboprophylaxis, incidence of VTE, bleeding events, hospital length of stay, in‐hospital mortality, 30‐day readmission for VTE. RESULTS Of the 410 patients included, 225 (55%) patients received thromboprophylaxis. For patients with international normalized ratio (INR) >2.0, a significant decrease in overall thromboprophylaxis use and pharmacologic prophylaxis use was seen compared to those with INR 1.4 to 2.0 (P = 0.013 and P < 0.001, respectively). Overall incidence of VTE was 0.7%. Fifteen bleeding events occurred (3.7%): 9 on mechanical prophylaxis, 1 on pharmacologic, 3 on combination, and 2 with no prophylaxis. The majority of patients experiencing a bleeding event had an INR >2.0 (P = 0.001). CONCLUSION The use of thromboprophylaxis in CLD patients is higher in our study than previous reports but remains suboptimal. Use of VTE pharmacologic prophylaxis does not appear to increase bleeding in CLD patients with INR ≤2.0. Further studies are needed to provide additional safety data. Journal of Hospital Medicine 2013;8:569–573. © 2013 Society of Hospital Medicine

Venous Thromboembolism in Liver Cirrhosis: An Emerging Issue

“…Dabbagh et al also confirmed that an elevated INR did not protect against the development of VTE during hospitalization [28]. Smith et al showed that the risk of in-hospital VTE was similar between patients with INR <2.0 and INR ≥2.0 [29]. Indeed, our team observed a positive relationship between INR and risk of VTE [30].…”

Anticoagulation in chronic liver disease

“…Despite this, several recent studies of anticoagulation in those with advanced fibrosis or cirrhosis appear to demonstrate acceptable safety profiles. Studies of VTE prophylaxis in cirrhotics patients have demonstrated no significantly increased risk of bleeding with anticoagulation (Intagliata et al, 2014;Smith et al, 2013, Barclay et al, 2013. Reichert and colleagues did demonstrate that if the INR was greater than 1.5, then the risk of bleeding was increased, but this was only for bleeding classified as of minor severity (Reichert et al, 2014) and stratification by type of anticoagulation has demonstrated that unfractionated heparin results in a higher bleeding risk than low molecular weight heparin in cirrhotic patients (Intagliata et al, 2014).…”

“…Studies investigating the relationship between the use of prophylactic anticoagulation in patients with cirrhosis and the risk of VTE have given contradictory results, perhaps reflecting the fact that these are predominantly retrospective studies with differences in coding and/ or means of defining cases of chronic liver disease, More specifically, some studies have failed to demonstrate a significant difference in the incidence of venous thromboembolic events in people with chronic liver disease given prophylactic anticoagulation compared to those who were not (Dabbagh et al, 2010), or observed no significant difference between incidence of VTE in those treated with pharmacological, mechanical or no prophylaxis (Smith et al, 2013). In contrast, other studies have shown a decreased incidence of VTE in patients with chronic liver disease given pharmacological prophylaxis (Barclay et al, 2013).…”

Biomarkers of liver dysfunction correlate with a prothrombotic and not with a prohaemorrhagic profile in patients with cirrhosis

“…7 However, in clinical settings, patients with liver cirrhosis are still broadly considered as having a bleeding diathesis, and increasing PT/INR and aPTT continue to be widely used as bleeding risk assessment parameters in patients with liver cirrhosis. 14,15 Moreover, several bleeding risk assessment scores include an abnormal liver function, which is differently defined by the various scores: increasing PT/INR, 16 biochemical evidence of liver dysfunction (HAS-BLED score; liver cirrhosis or increased bilirubin and transaminases) 17 or not specified (HEMORR2AGES score). 18 This contradicts the accumulating evidence of a procoagulant profile in patients with liver cirrhosis, which worsens in parallel to cirrhosis severity.…”