Reversal agents for oral anticoagulant-associated major or life-threatening bleeding

Marco Moia, Alessandro Squizzato

Research output: Contribution to journalReview article

Abstract

Oral anticoagulants (OA) are effective drugs for treating and preventing the formation of blood clots in patients with atrial fibrillation, mechanical heart valves and venous thromboembolism but their therapeutic effect is always counterbalanced by an increased risk of bleeding. Direct oral anticoagulants (DOACs) have brought advantages in the management of many patients, with evidence of a lower risk of intracranial bleeding in comparison to vitamin K antagonists (VKAs). However, due to the increased number of anticoagulated patients worldwide, major and life threatening OA-related bleeding is also increasing, and effective reversal strategies are needed. We reviewed the reversal strategies for both VKAs and DOACs in the light of the latest evidence and recent guidelines, taking into account non-specific methods with fresh frozen plasma (FFP), prothrombin complex concentrate (PCC) or four factor PCC, as well as specific reversal antidotes that are already approved or in approval phase. Most published studies on OA reversal have drawbacks, such as lacking a control arm or data on clinically relevant outcomes, and current guidelines’ recommendations are mainly based on panellists’ judgment. There is an urgent need for well-designed studies in this field. In the meanwhile, to improve the correct use of available resources and patients’ outcomes, we suggest a seven-element bundle for an optimal management of OA-associated major bleeding, including the implementation of fast turnaround time for laboratory tests in emergency, i.e. INR and DOAC plasma levels, and to build up a ‘bleeding team’ that includes experts of hemostasis, lab, trauma, emergency medicine, endoscopy, radiology, and surgery in every hospital.

Original languageEnglish
Pages (from-to)1233-1239
JournalInternal and Emergency Medicine
Volume14
Issue number8
DOIs
Publication statusPublished - 2019

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Anticoagulants
Hemorrhage
Vitamin K
Guidelines
Antidotes
International Normalized Ratio
Emergency Medicine
Heart Valves
Venous Thromboembolism
Therapeutic Uses
Hemostasis
Radiology
Atrial Fibrillation
Endoscopy
Emergencies
Thrombosis
Wounds and Injuries

Keywords

  • Andexanet
  • Bleeding
  • Direct oral anticoagulant
  • Idarucizumab
  • Prothrombin concentrate complex
  • Vitamin K antagonist

ASJC Scopus subject areas

  • Internal Medicine
  • Emergency Medicine

Cite this

Reversal agents for oral anticoagulant-associated major or life-threatening bleeding. / Moia, Marco; Squizzato, Alessandro.

In: Internal and Emergency Medicine, Vol. 14, No. 8, 2019, p. 1233-1239.

Research output: Contribution to journalReview article

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