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EDUCATION IN THE MANAGEMENT OF BLEEDING

A practical, evidence-based guide for front-line physicians on how to Treat the Bleed

How do I treat a patient with a life-threatening bleed on a DOAC?

DOAC Figure Q4

General approach as follows:

  1. Risk stratification should first occur, ideally with expert consultation
    • Assessment should include:
      • Assessing hemodynamic stability
      • Taking a bleeding history and determining the source of bleeding
      • Medication history, including last dose and interactions
      • Pre-existing anemia and renal failure
    • Consider life-threatening bleeds, including: hemodynamic instability, transfusion of ≥3 units of red blood cells in 1 hour, end organ damage from anemia
  2. Stop the drug
  3. Consider activated charcoal if last dose within 2-3 hours for highest risk, most severe bleeds
  4. Consider testing to rule in/out the presence of therapeutic DOAC levels ( See question #2)
    • Do NOT wait until testing comes back before acting
  5. Supportive care
    • Includes wide-bore IV access and transfer to a monitored setting
    • Blood transfusion should occur similarly to non-DOAC bleeding
      • Consider an Hb target of 70 g/L in GI bleeding
      • Plasma is often not initially needed in liver disease/upper GI bleeding
      • Plasma is not indicated for DOAC “reversal”
      • Platelets should generally be transfused if below 50 x 109/L
      • Check fibrinogen levels, if possible
  6. Local hemostasis
    • Mechanical compression and local hemostatic measures
    • Surgical and interventional radiology procedures that definitively stop the bleeding, even with the use of coagulation products and reversal agents, are the cornerstones of therapy
  7. Tranexamic acid
    • Should be strongly considered in DOAC-associated bleeding, though it has not been studied specifically in this population
  8. Specific DOAC reversal agents whenever possible ( See question #3)
    • Dabigatran: idarucizumab
    • Factor-Xa inhibitors (apixaban, edoxaban, rivaroxaban): andexanet alfa (not commonly available in Canada)
  9. Non-specific agents to treat DOAC-associated bleeding – if specific DOAC reversal agents not available
    • Dabigatran: hemodialysis and/or activated prothrombin complex concentrates (aPCCs) can be considered if idarucizumab not available, but rebound often occurs quickly after hemodialysis
    • Factor-Xa inhibitors (apixaban, edoxaban, rivaroxaban): PCCs 2000 IU (or 25-50 IU/kg to max 3000 IU) is likely the best alternative therapy without a specific reversal agent
      • Precise dose is unknown due to lack of dose-ranging studies
    • Other non-specific agents/considerations
      • Use of recombinant factor VIIa is not recommended, due to evidence of harm
      • No evidence that frozen plasma transfusion has any effect in DOAC bleeding management

Surgical and interventional radiology procedures that definitively stop the bleeding, even with the use of coagulation products and reversal agents, are the cornerstones of therapy.

References:

  1. Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94:697-709.
  2. Piran S, Khatib R, Schulman S, et al. Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv. 2019;3:158-167.
  3. Schulman S. Bleeding Complications and Management on anticoagulant therapy. Semin Thromb Hemost. 2017;43:886-892.
  4. Shih AW, Crowther MA. Reversal of Direct Oral Anticoagulants: A Practical Approach. Hematology Am Soc Hematol Educ Program. 2016;612-619.
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding