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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

When should I consider repeat dosing of the reversal agent or PCC if my patient is still bleeding?

For information on DOAC reversal agents, See question #3

DOAC Figure Q7

Direct thrombin inhibitor (dabigatran) associated bleeding after idarucizumab administration:

  • Administration of an additional dose of idarucizumab 5 g may be considered if:
    • Clinically significant bleeding together with an increase in thrombin time occurs 12-24 hours after administration of the standard dose of idarucizumab 5 g

Factor Xa inhibitor (apixaban, edoxaban, rivaroxaban) associated bleeding after PCC administration:

  • Administration of an additional dose of PCC may be considered if:
    • Visible evidence of bleeding 4 hours or more after the initial PCC dose administration
    • Patient clinical condition has deteriorated with clinical evidence of poor hemostasis (e.g., >20% decrease in both Hb and Hct, or evidence of significant hematoma expansion on imaging within 24 hours from the initial PCC dose administration)

Factor Xa inhibitor (apixaban, edoxaban, rivaroxaban) associated bleeding after andexanet alfa administration:

  • The safety and efficacy of more than one dose has not been clinically evaluated and cannot be recommended by the manufacturer
  • PCC use may be considered, but consideration must be given to balancing thrombosis risk in the patient

References:

  1. Andexxa® (Andexanet alfa) Package Insert. San Francisco, CA, USA; Portola Pharmaceuticals Inc. December 2018.
  2. Praxbind® (Idarucizumab) Product Monograph. Burlington, Ontario; Boehringer Ingelheim Canada Ltd. April 18, 2019.
  3. Schulman S, Gross PL, Ritchie B, et al. Prothrombin complex concentrate for major bleeding on factor Xa inhibitors: a prospective cohort study. Thromb Haemost. 2018;118:842-851. 
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding