Author + information
- Received January 3, 2018
- Revision received March 3, 2018
- Accepted March 6, 2018
- Published online May 7, 2018.
- Arman Qamar, MDa,
- Muthiah Vaduganathan, MD, MPHb,
- Norton J. Greenberger, MDc and
- Robert P. Giugliano, MD, SMa,∗ ()
- aTIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- bHeart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- cGastroenterology, Hepatology, and Endoscopy Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Robert P. Giugliano, TIMI Study Group, Brigham and Women’s Hospital, 60 Fenwood Avenue, Suite 7022, Boston, Massachusetts 02115.
Patients with liver disease are at increased risks of both thrombotic and bleeding complications. Many have atrial fibrillation (AF) or venous thromboembolism (VTE) necessitating oral anticoagulant agents (OACs). Recent evidence has contradicted the assumption that patients with liver disease are “auto-anticoagulated” and thus protected from thrombotic events. Warfarin and non–vitamin K–antagonist OACs have been shown to reduce thrombotic events safely in patients with either AF or VTE. However, patients with liver disease have largely been excluded from trials of OACs. Because all currently approved OACs undergo metabolism in the liver, hepatic dysfunction may cause increased bleeding. Thus, the optimal anticoagulation strategy for patients with AF or VTE who have liver disease remains unclear. This review discusses pharmacokinetic and clinical studies evaluating the efficacy and safety of OACs in patients with liver disease and provides a practical, clinically oriented approach to the management of OAC therapy in this population.
Drs. Qamar and Vaduganathan are supported by the National Heart, Lung, and Blood Institute T32 post-doctoral training grant (T32HL007604). Dr. Greenberger has served on the hepatic clinical endpoint committee of the ENGAGE AF-TIMI 48 trial funded by Daiichi-Sankyo. Dr. Giugliano’s institution has received research grants from Daiichi-Sankyo to support the ENGAGE AF-TIMI 48 trial; honoraria for continuing medical education programs from Daiichi-Sankyo and the American College of Cardiology; and is a compensated consultant for Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi-Sankyo, Merck, Portola, and Pfizer.
- Received January 3, 2018.
- Revision received March 3, 2018.
- Accepted March 6, 2018.
- 2018 American College of Cardiology Foundation
- Central Illustration
- Burden of Thrombotic Complications in Patients With Liver Disease
- Mechanisms Driving Bleeding and Thrombosis in Liver Disease
- Warfarin in Liver Disease
- The Use of NOACs in Liver Disease
- Hepatic Pharmacokinetics and Pharmacodynamics of NOACs
- OACs and the Risk of Liver Injury
- Gastroprotection in Patients With Liver Disease Who Are Taking OACs
- Management of Bleeding in Patients With Liver Disease Who Are Taking OACs
- Practical Approach to the Prescription of OACs in Liver Disease
- Conclusions and Future Directions