![]() ![]() For patients who are clinically stable and who do not have advanced renal disease or a history of heparin-induced thrombocytopenia, warfarin can usually be safely initiated in the outpatient setting with bridging therapeutic-dose LMWH. Additionally, the indication for anticoagulation and the goal INR therapeutic range ( Table 1) should be notated in the medical record. In many cases, this requires a physician-to-physician conversation, as only one office should be responsible for anticoagulation management of the patient. Prior to the initiation of anticoagulation therapy, the patient’s primary care physician should be contacted to discuss indications for therapy and identify which office will be primarily responsible for long-term anticoagulation management. 2Īnticoagulation therapy must be individualized, based on each patient’s liver function status, the presence of portal hypertension, previous bleeding events, current risk of bleeding, plans for invasive procedures, and risk for falls. Since patients receiving treatment with enoxaparin decompensated less than the controls, this study also suggests that enoxaparin prevents microvascular thrombosis and slows parenchymal extinction, suggesting that Dr Ian Wanless was right all along. Kaplan-Meier estimates showed a higher rate of survival in the enoxaparin-treated group compared with the control group ( P=.020). Further, liver decompensation occurred more commonly in patients in the control group compared with patients treated with enoxaparin (59.4% vs 11.7% P<.0001). ![]() During the follow-up period, off therapy, 3 enoxaparin-treated patients developed a portal vein thrombosis, at weeks 105, 111, and 121 after enrollment. This benefit was extended to 96 weeks, at which time, none of the enoxaparin group had developed a portal vein thrombosis, compared with 10 of 36 patients (27.7%) in the control group ( P=.001). By 48 weeks, 6 of the 36 patients (16.6%) in the control group had developed a portal vein thrombosis, compared with no patients in the enoxaparin group ( P=.025). ![]() 1 In this study, 70 Italian outpatients with cirrhosis were randomly assigned to receive prophylactic enoxaparin or no treatment for 48 weeks. The effectiveness of anticoagulation with enoxaparin, a low-molecular-weight heparin (LMWH), in preventing portal vein thrombosis in patients with advanced cirrhosis was demonstrated in a randomized, controlled trial. This coagulation assessment with TEG/ROTEM is of critical importance in patients with acute liver failure. Once cirrhosis with synthetic dysfunction is evident, a full evaluation for bleeding and clotting risk is needed (including thromboelastography /rotational thromboelastometry ). All coagulation factors are synthesized by the liver (with the notable exceptions of factor VWF:VIII and Ca++), and thus PT/INR can be crudely used to measure the liver’s synthetic ability. Another major event, which occurs later in the course of the disease in most patients, is prolongation of the prothrombin time (PT)/international normalized ratio (INR). The first 2 signs are a reduction in the serum albumin level, which reflects the reduced capacity of the liver to synthesize albumin, and increased direct bilirubin. At this point, patients usually exhibit subtle clinical signs of liver failure, evident as synthetic dysfunction that manifests in several ways. Most patients with chronic liver disease do not manifest clotting disorders until they develop cirrhosis. Patients With Cirrhosis and Underlying Synthetic Dysfunction He has performed research for Gilead and DURECT. ![]() In the past 2 years, Dr Flamm has been a consultant for AbbVie, Gilead, Salix, Intercept, and Mallinckrodt. He is a member of the Data Safety Monitoring Board of Arrowhead. He is an advisory consultant for the diagnostic companies BioCollections, Fujifilm/Wako, and Quest. He is the Chair of the Clinical Advisory Board of Prodigy. He is a member of the Clinical Trials Alliance of Topography Health. He is currently active on the scientific or clinical advisory boards of Abbott, AbbVie, Merck, Arrowhead, Bayer, Dova Pharmaceuticals, Eiger, Enyo, HepQuant, Intercept, and Janssen. He has performed as a consultant and/or advisor (in the last 2 years) to Abbott, AbbVie, Access Biologicals, Antios, Arrowhead, Bayer AG, Bristol-Myers Squibb Company, Dova, Dynavax, Eiger, Eisai, Enyo, eStudySite, Forty-Seven Inc, Genentech, Genlantis, Gerson Lehrman Group, Gilead Sciences, HepaTx, HepQuant, Intercept, Janssen, Helios, Lilly, Merck, Salix, Shionogi, and Viking Therapeutics. In the past 2 years, Dr Gish has received grants/research support from Gilead. ![]()
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