Management of bleeding in patients receiving direct oral anticoagulants
- David A Garcia, MD
David A Garcia, MD
- Professor of Medicine, Division of Hematology
- University of Washington School of Medicine
- Mark Crowther, MD, MSc
Mark Crowther, MD, MSc
- Professor of Medicine and Pathology & Molecular Medicine
- St Joseph’s Hospital and McMaster University
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
The use of any anticoagulant is associated with an increased risk of bleeding, and bleeding complications can be life-threatening. Bleeding is especially concerning with the direct oral anticoagulants (DOACs) because antidotes or specific reversal agents for some of the DOACs are lacking. Additionally, routine coagulation tests cannot be used to determine the degree of anticoagulation, making it more challenging to determine when the anticoagulant effect has resolved.
This topic discusses our approach to managing bleeding in patients receiving DOACs. Specific indications for these agents, details of administration and monitoring, and perioperative management of these agents are presented separately. (See "Direct oral anticoagulants and parenteral direct thrombin inhibitors: Dosing and adverse effects" and "Atrial fibrillation: Anticoagulant therapy to prevent embolization" and "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Perioperative management of patients receiving anticoagulants" and "Venous thromboembolism: Initiation of anticoagulation (first 10 days)".)
TERMINOLOGY AND SITES OF ACTION
Terminology for oral anticoagulants has been in flux as individual agents become more familiar (less new) and additional agents become available. We use the following terminology:
●Direct oral anticoagulants (DOACs) – DOACs are oral medications that inhibit a specific enzyme in the coagulation cascade. A consensus document regarding terminology for these agents has been published; although no single term emerged as the obviously best term, DOAC was preferred by the most experts surveyed . These medications are also called target-specific oral anticoagulants (TSOACs), oral direct inhibitors (ODIs), or referred to by their individual names or the enzyme they inhibit. We prefer to avoid the terms "novel oral anticoagulant" and "new(er) oral anticoagulant" (NOAC) because over time each agent ceases to be novel or new. Some clinicians refer to this group of agents as "non-vitamin K antagonist oral anticoagulants", to retain the NOAC acronym.
Available agents include those that directly inhibit thrombin (factor IIa) or factor Xa. The positions of these enzymes in the coagulation cascade are illustrated in the figure (figure 1) and discussed in detail separately. (See "Overview of hemostasis".)
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- TERMINOLOGY AND SITES OF ACTION
- BLEEDING RISKS FROM DOACs
- Clinical outcomes
- Risk of bleeding
- PATIENT ASSESSMENT
- Initial assessment
- Assessment of bleeding
- Assessment of anticoagulation status
- - Interval since last dose
- - Renal and hepatic function
- - Coagulation testing
- Other limited laboratory testing
- MAJOR BLEEDING
- Overview of management
- Anticoagulant reversal
- - Overview of reversal strategy
- - Dabigatran reversal
- - Rivaroxaban, apixaban, edoxaban (reversal)
- Clotting factor products
- Antifibrinolytics and other pro-hemostatic therapies
- Transfusions if needed
- MINOR BLEEDING
- SURGERY/INVASIVE PROCEDURE
- RESUMPTION OF ANTICOAGULATION
- ANTIDOTES UNDER DEVELOPMENT
- SUMMARY AND RECOMMENDATIONS