Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 27, 2019; 11(4): 379-390
Published online Apr 27, 2019. doi: 10.4254/wjh.v11.i4.379
Effectiveness of venous thromboembolism prophylaxis in patients with liver disease
Jason Yerke, Seth R. Bauer, Stephanie Bass, Heather Torbic, Michael Militello, Erin Roach, Ibrahim Hanouneh, Sarah Welch
Jason Yerke, Seth R. Bauer, Stephanie Bass, Heather Torbic, Michael Militello, Sarah Welch, Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
Erin Roach, Department of Pharmacy, Carolinas Medical Center, Charlotte, NC 28203, United States
Ibrahim Hanouneh, Department of Gastroenterology, Mayo Clinic, Rochester, MN 55905, United States
Author contributions: Yerke J, Welch S, Bauer S, Bass S, Torbic H and Militello M conceived the research study design; Yerke J collected data; Yerke J and Welch S interpreted data; Yerke J drafted the manuscript; Yerke J, Welch S, Bauer S, Bass S, Torbic H, Militello M, Hanouneh I and Roach E critically revised the manuscript.
Supported by: Cleveland Clinic Department of Pharmacy.
Institutional review board statement: The study was reviewed and approved by the Cleveland Clinic Foundation Institutional Review Board.
Conflict-of-interest statement: Dr. Hanouneh reports personal fees from Merck and Co., personal fees from Dova Pharmaceuticals, personal fees from Gilead Sciences, Inc., outside the submitted work; all other authors report no potential conflicts of interest.
STROBE statement: The authors have read the STROBE statement checklist of items, and the manuscript was prepared and revised according to the STROBE statement checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jason Yerke, PharmD, Pharmacist, Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
Telephone: +1-216-4425553
Received: January 10, 2019
Peer-review started: January 10, 2019
First decision: March 5, 2019
Revised: March 22, 2019
Accepted: April 8, 2019
Article in press: April 8, 2019
Published online: April 27, 2019

Patients with liver disease are concomitantly at increased risk of venous thromboembolism (VTE) and bleeding events due to changes in the balance of pro- and anti-hemostatic substances. As such, recommendations for the use of pharmacological VTE prophylaxis are lacking. Recent studies have found no difference in rates of VTE in those receiving and not receiving pharmacological VTE prophylaxis, though most studies have been small. Thus, our study sought to establish if pharmacological VTE prophylaxis is effective and safe in patients with liver disease.


To determine if there is net clinical benefit to providing pharmacological VTE prophylaxis to cirrhotic patients.


In this retrospective study, 1806 patients were propensity matched to assess if pharmacological VTE prophylaxis is effective and safe in patients with cirrhosis. Patients were divided and evaluated based on receipt of pharmacological VTE prophylaxis.


The composite primary outcome of VTE or major bleeding was more common in the no prophylaxis group than the prophylaxis group (8.7% vs 5.1%, P = 0.002), though this outcome was driven by higher rates of major bleeding (6.9% vs 2.9%, P < 0.001) rather than VTE (1.9% vs 2.2%, P = 0.62). There was no difference in length of stay or in-hospital mortality between groups. Pharmacological VTE prophylaxis was independently associated with lower rates of major bleeding (OR = 0.42, 95%CI: 0.25-0.68, P = 0.0005), but was not protective against VTE on multivariable analysis.


Pharmacological VTE prophylaxis was not associated with a significant reduction in the rate of VTE in patients with liver disease, though no increase in major bleeding events was observed.

Keywords: Fibrosis, Venous thromboembolism, Venous thrombosis, Liver, Embolism

Core tip: While patients with cirrhosis have historically been considered to be coagulopathic, recent data suggests that these patients may be both hypo- and hypercoagulable. Recommendation for provision of chemoprophylaxis to prevent venous thromboembolism (VTE) in this group of patients is lacking. In our study, pharmacological VTE prophylaxis decreased composite rates of major bleeding and VTE but was not protective against VTE, further demonstrating the uncertain utility of chemoprophylaxis in this population.