A framework for managing severe DOAC-related bleeding: Recognize, Reverse, Resume, Reduce

Bleeding is the main complication of treatment with anticoagulants, the most common adverse drug event that leads to emergency department visits, hospital admission, and death. While direct oral anticoagulants (DOACs) reduce the risk of major, fatal and intracranial bleeding compared to vitamin K antagonists, DOAC-associated bleeding is associated with substantial short-term mortality rates. To optimize management and improve outcomes, a standardized approach to managing severe bleeding includes rapid recognition, provision of treatments to reverse anticoagulation or enhance hemostasis, resumption of anticoagulation safety after bleed cessation and attention to secondary prevention measures and long-term monitoring. This narrative review outlines a pragmatic multimodal framework for severe DOAC bleed management with case examples to illustrate key principles.