A new clinical practice guideline from the American Gastroenterological Association (AGA) addressed the management of coagulation disorders in patients with cirrhosis.
In the guideline, the AGA suggested against extensive preprocedural testing, including repeated measurements of prothrombin time/international normalized ratio or platelet count, in those with stable disease who are undergoing common GI procedures such as paracentesis, thoracentesis, variceal banding, colonic polypectomy, and liver biopsy. The AGA made no recommendation regarding use of preprocedural visco-elastic testing in this group to determine bleeding risk.
The guideline suggested against routine use of blood products, such as fresh frozen plasma and platelets, for bleeding prophylaxis in patients with stable cirrhosis undergoing common GI procedures. The authors noted that this recommendation applies to most patients with stable cirrhosis, who usually do not have severe thrombocytopenia or severe coagulopathy. “In patients with severe derangements in coagulation or thrombocytopenia undergoing a procedure that is high risk for bleeding, decisions about prophylactic blood transfusions should include discussions about potential benefits and risks (including transfusion reactions and delay of procedure) in consultation with a hematologist,” they wrote.
In patients with thrombocytopenia and stable cirrhosis who are undergoing common procedures, particularly those considered low risk, the AGA suggested against the routine use of thrombopoietin-receptor agonists for bleeding prophylaxis but noted that they might be reasonable in patients who value uncertain reduction of procedural bleeding events highly and put a low value on increased risk for portal vein thrombosis. The AGA also suggested standard anticoagulation prophylaxis for venous thromboembolism over no anticoagulation in hospitalized patients with cirrhosis.
The guideline also covered screening for portal vein thrombosis, anticoagulation for treatment of portal vein thrombosis, and use of anticoagulation in patients with cirrhosis and atrial fibrillation. All of the recommendations in the guideline are conditional, with very low-certainty evidence.
The guideline was developed by the AGA Institute's Clinical Guideline Committee and was approved by the AGA Governing Board. The guideline and an accompanying technical review were published online Sept. 24 by Gastroenterology and appeared in the Nov. 1 issue.