Key result
In the absence of specific antidotes, urgent reversal of life-threatening bleeding associated with direct oral anticoagulants relies on non-specific agents such as prothrombin complex concentrates.
In the absence of specific antidotes, this review provides a practical framework for the emergency reversal of DOACs using non-specific pro-hemostatic agents, hemodialysis, and general support measures.
Guides emergency DOAC reversal with PCCs in the absence of antidotes; leaves open optimal protocols pending further validation.
Bleeding represents the most feared complication of the new oral anticoagulants, direct oral anticoagulants (DOACs), as well as all the antithrombotic therapies. During the acute phase of bleeding in patients taking anticoagulants, restoration of an effective hemostasis represents the cornerstone of practical management. While vitamin K antagonists are effectively and promptly reversed by specific antidotes such as prothrombin complex concentrates (PCCs), fresh frozen plasma or vitamin K, it is still not clear how to manage the urgent reversal of DOACs during life-threatening or major bleedings due to the lack of specific antidotes. However, in vitro and ex vivo studies have suggested some potential strategies to reverse DOACs in clinical practice, other than general support measures that are always recommended. Activated charcoal could be used in subjects with DOAC-related bleedings presenting to the emergency department within two hours of the last oral intake. Non-activated or activated PCCs (FEIBA) and recombinant activated Factor VII (raFVII) seem to be the optimal strategy for urgent reversal of dabigatran, while non-activated PCCs seem to have efficacy in reversing rivaroxaban. Due to its low plasma protein binding, dabigatran could be also dialyzed in urgent cases. Clinically relevant non-major bleedings and minor bleedings should be treated with general and local measures, respectively, and, when necessary, with dose delay or drug withdrawal. In this article, the Authors describe the practical approach to bleedings occurring during DOACs treatment.
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Masotti et al. (2013) conducted a review in Bleeding during treatment with direct oral anticoagulants. Emergency reversal therapy (PCCs, FFP, raFVII, activated charcoal, hemodialysis) was evaluated. In the absence of specific antidotes, urgent reversal of life-threatening bleeding associated with direct oral anticoagulants relies on non-specific agents such as prothrombin complex concentrates.
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