Recommendations for Anticoagulation Use in Patients With Liver Disease

Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR	LOE	Recommendations
2a	B-NR	1. For patients with AF who are at increased risk of systemic thromboembolism and mild or moderate liver disease (Child-Pugh* class A or B), OAC therapy is reasonable in the absence of clinically significant liver disease–induced coagulopathy or thrombocytopenia.1–7
2a	B-NR	2. For patients with AF who are at increased risk of systemic thromboembolism and mild or moderate liver disease (Child-Pugh class A or B) and who are deemed to be candidates for anticoagulation, it is reasonable to prescribe DOACs (Child-Pugh class A: any DOAC; Child-Pugh class B: apixaban, dabigatran, or edoxaban) over warfarin.1,7–11
3: Harm	C-LD	3. For patients with AF and moderate liver disease (Child-Pugh class B) at increased risk of systemic thromboembolism, rivaroxaban is contraindicated due to the potentially increased risk of bleeding.12

^*Child-Pugh scoring: the severity of liver disease, primarily cirrhosis in patients with diagnosed liver disease. Child-Pugh A (mild): 5–6 points; Child-Pugh B (moderate): 7–9 points; Child-Pugh C (severe): 10–15 points. The score is based on the 5 variables: encephalopathy (none=1 point, grade 1 and 2=2 points, grade 3 and 4=3 points); ascites (none=1 point, slight=2 points, moderate=3 points); total bilirubin (<2 mg/mL=1 point, 2–3 mg/mL=2 points, >3 mg/mL=3 points); albumin (>3.5 mg/mL=1 point, 2.8–3.5 mg/mL=2 points, <2.8 mg/mL=3 points); INR (<1.7=1 point, INR 1.7–2.2=2 points, INR >2.2=3 points).