Key result
A proposed decision algorithm for DOAC-related bleeding management highlights the use of point-of-care testing and specific reversal agents to achieve effective hemostasis.
Why the study?
Life-threatening bleeding under DOACs requires rapid assessment of plasma concentration, but standard tests are insensitive and specific assays are often slow or unavailable, prompting the need for a practical decision algorithm.
This expert opinion provides a clinical decision algorithm for managing bleeding events in patients on DOACs, emphasizing the role of specific assays, point-of-care testing, and targeted reversal agents.
May inform DOAC bleeding decisions at bedside; leaves open need for prospective validation before adoption.
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
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Heubner et al. (2023) conducted a review in Bleeding events in patients on direct oral anticoagulants (DOAC). Bleeding management strategies (point-of-care testing and reversal agents) was evaluated. A proposed decision algorithm for DOAC-related bleeding management highlights the use of point-of-care testing and specific reversal agents to achieve effective hemostasis.
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