Takeaway
- For bleeding patients taking anticoagulants, reversal or factor replacement may be necessary but should not crowd out supportive care, source control, consults.
Why this matters
- Anticoagulant use is rising, thanks to expanding indications, growing geriatric population.
Description
- Multidisciplinary consensus on:
- Assessing bleeding patients who take anticoagulant.
- Reversing anticoagulants, replacing coagulation factors.
- Definitions of life-threatening bleeding, bleeding at critical site, and emergency surgery or urgent invasive procedure.
Key details
- To determine who requires reversal/replacement, consider, e.g.:
- Amount, time of last dose.
- Whether bleeding is life-threatening or in critical site.
- If reversal/replacement is necessary:
- Do not neglect supportive care.
- Control source via compression, surgery, endoscopy, or interventional radiology.
- Use labs to risk-stratify and identify comorbidities.
- Nonbleeding patients may require reversal if:
- Emergent procedure needed.
- They overdosed on vitamin K antagonist (VKA).
- Reversal options:
- Antiplatelet agents: consider desmopressin (DDAVP, Ferring).
- Platelet transfusion is of unclear benefit.
- Apixaban (Eliquis, Bristol-Myers Squibb) and rivaroxaban (Xarelto, Janssen): andexanet alfa (Andexxa, Portola; all FDA-approved).
- Dabigatran (Pradaxa, Boehringer Ingelheim): idarucizumab (Praxbind, Boehringer Ingelheim; FDA-approved).
- VKAs: 4-factor prothrombin complex concentrate (PCC; Kcentra, CSL Behring; FDA-approved); multiple unapproved options.
- Direct oral anticoagulants: (activated) PCC (limited data).
- For overdose:
- Monitor for 2-5 half-lives.
- Consider Poison Control consult, especially if, e.g., synthetic VKAs.
References
References