The role of anti-fibrinolytics, rFVIIa and other pro-coagulants: prophylactic versus rescue?

Patients who have liver disease experience an increased risk for bleeding and resulting complications. Diseases affecting the liver can cause a deficiency of pro-coagulant factors or induce a state of increased clot breakdown. Although traditional tests of coagulation, such as prothrombin time or international normalized ratio (INR), may not accurately measure bleeding risk, many studies have assessed measures used to correct an increased INR and minimize adverse outcomes. This article discusses the use of activated factor VIIa and anti-fibrinolytic agents to treat coagulopathy in the setting of liver disease and the potential advantages and disadvantages of these alternatives, and the limitations of the current literature. This article also compares the limitations, risks, and potential benefits of prophylactic therapy to prevent bleeding before invasive procedures with rescue therapy for spontaneous and postprocedure bleeding, and describes the relative advantages and disadvantages of these two approaches.