Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants

Abstract

purpose. Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DoaCs) is reviewed.Summary. over the past five years, a new generation of oral agents, the DoaCs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. management of a bleeding event in the setting of DoaC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. beyond withholding the DoaC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. Conclusion.With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DoaCs.Am J Health-Syst Pharm. 2016; 73(suppl 2):s14-26

In vitro and ex vivo Measurement of Prophylactic Dabigatran Concentrations with a New Ecarin-Based Thromboelastometry Test

“…The resulting shorter turnaround times (5-10 min vs. 30-45 min for ecarin CT vs. diluted thrombin time) may allow for an expedited diagnosis in order to initiate emergency treatment. This would be in line with current guidelines for the management of bleeding events or urgent surgery, which recommend laboratory testing of the dabigatran concentration and dabigatran effects prior to reversal [15][16][17][18][19].…”

Management of Dabigatran‐Associated Bleeding with Two Doses of Idarucizumab Plus Hemodialysis

“…Before the approval of idarucizumab, methods for reversing the anticoagulant effect of dabigatran had not been extensively studied. Coagulation factors studied for the reversal of dabigatran include prothrombin complex concentrates (PCC3 and PCC4), activated PCCs (aPCCs), and recombinant factor VIIa (rFVIIa) . A double‐blind, randomized, controlled trial of 12 healthy male volunteers who received dabigatran 150 mg twice/day for 2.5 days followed by 50 IU of four‐factor PCC/kg found no effect on aPTT, ECT, and TT .…”

Overview of direct oral anticoagulant therapy reversal

“…Dialysis could be considered for some patients receiving dabigatran, though line placement could be challenging without more active reversal. Laboratory testing, as described in the article by Dager and Hellwig, 26 should be used to help determine the rate and extent of clearance of the DOAC. level of urgency: emergent (immediate reversal needed in less than one hour).…”