Reversing DOACs



Major or life threatening bleeding

  • Intracranial bleed
  • Retroperitoneal bleed/Intra-ocular bleed
  • Muscle bleed, with compartment syndrome
  • Pericardial bleed
  • Active bleed with ↓BP or 3g fall in Hb

PCC (Octaplex) dose in Major Bleed (warfarin)
Patients INR Dose PCC
INR 2 - 3.9 25 IU / Kg
INR 4 - 6 35 IU / Kg
INR > 6 50 IU / Kg

A single dose of Octaplex® should NOT exceed 3000 IU (i.e. 120 mL Octaplex®)

If the calculated dose exceeds 3000 IU, administer the 3000 IU, then repeat the INR and seek advice from haematology.

Please check INR 30 mins post PCC infusion.


Reversing


Reversing Dabigatran

Contact haematology SpR - re Idarucizumab.

Dabigatran is an oral direct thrombin inhibitor (DTI) licensed for stroke prevention in atrial fibrillation.

Unlike warfarin, the PT/INR response to Dabigatran is inconsistent and should not be measured.

The activated partial thromboplastin time (APTT) provides a qualitative measurement of the anticoagulant effect of Dabigatran. Knowledge of the time of last dose is important for interpretation of the APTT.

If a patient receiving Dabigatran presents with bleeding:

  • Omit/delay next dose of Dabigatran
  • Measure APTT and PT (consider DTI assay if available)
  • Consider charcoal, with sorbitol, if within 2 h of ingestion
  • Give TXA - 1 g IV if significant bleed (TXA infusion guide)
  • Involve haematology team re Idarucizumab or PCC
  • Maintain renal perfusion to aid excretion
  • Dabigatran - low protein binding - removed by dialysis

Reversing Rivaroxaban (Xarelto®)

The PT/INR/APTT responses to Rivaroxaban are not reliable.

  • Omit/delay next dose of Rivaroxaban
  • If available, use Andexanet Alfa: adults only
  • Consider charcoal, with sorbitol, if within 2 h of ingestion
  • PCC at 50 IU/Kg (max 2000 IU)

Reversing LMWH

  • Consider Protamine 10mg/1000iu heparin infused / LMWH to a max of 7.5ml (75mg)

Anticoagulant reversal - Summary

Drug Mech. of action Half-life Emergency Reversal
Warfarin Vitamin K antagonist 20-60 hours Vitamin K 5g IV ± PCC 25-50 U/kg
DOACs Mech. of action Half-life Emergency Reversal
Dabigatran Thrombin inhibitor 9 hours (renal fxn.) TXA 1g IV ± Idaruciumab (€) 5g IV
Rivaroxaban Factor Xa inhibitor 9 hours (renal fxn.) Andexanet or PCC 50 U/kg
Apixaban Factor Xa inhibitor Andexanet or PCC 50 U/kg
Edoxaban Factor Xa inhibitor Andexanet or PCC 50 U/kg
Antiplatelets Mech. of action Half-life Emergency Reversal
Aspirin Irreversibly inhibits COX1 5-7 days Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma)
Clopidogrel Irreversible inhibits P2YI2 receptors 5-7 days Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma)
Prasugrel Irreversible inhibits P2YI2 receptors 5-7 days Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma)
Ticagrelor Irreversible inhibits P2YI2 receptors 5-7 days Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma)
Dipyridamole Phosphodiesterase inhibitor 24 hours Platelet transfusion (low-level evidence). Desmopressin (caution with contraindications and limited evidence in trauma)



Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS Dr Karol O'Donovan 24/03/24.