Balancing Thrombosis and Bleeding: Antithrombotic Therapy in Cirrhosis-Related Thrombocytopenia

The development of thrombocytopenia is common in cirrhosis. Further complex alterations in haemostasis also occur, resulting in a rebalanced state that predisposes patients to both thromboembolic and bleeding complications. Guidance on the management of thrombosis in patients with cirrhosis-related thrombocytopenia is limited and poses a common clinical dilemma. Anticoagulation in this population remains challenging due to altered drug pharmacokinetics, baseline abnormalities in conventional coagulation tests, limitations in laboratory monitoring, thrombocytopenia itself and concerns regarding bleeding risk. Low-molecular-weight heparin and vitamin K antagonists have traditionally been used; however, increasing data support the use of direct oral anticoagulants in patients with compensated cirrhosis. Management decisions should be individualised, incorporating liver disease severity, thrombotic burden, bleeding risk, and clinical factors such as portal hypertension. This review summarises current evidence on thromboembolic disease and antithrombotic therapy in cirrhosis-related thrombocytopenia. Further prospective studies are required to investigate key knowledge gaps, including optimal platelet thresholds for anticoagulation use and the role of functional coagulation testing in this population.