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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

What should be considered before I re-start the patient on a DOAC?

Consultation with a hematologist or thrombosis expert is strongly recommended before re-starting DOAC in someone who has experienced a life-threatening bleed.

Is the indication for a DOAC strong enough to justify the increased risk of recurrent bleed?  The bleeding risk on a DOAC outweighs its benefit and should not be restarted in the following situations:  Provoked VTE Remote history of unprovoked VTE (1 year previously) Atrial fibrillation with very low risk of stroke (CHADS2 score 0-1) Others? Can the DOAC dose be reduced? If a non-life threatening but clinically significant bleed has occurred Reassess after 6-12 months Consequences of a recurrent major bleed? Critical organ – wait is longer before the DOAC could be restarted CNS: 1 month for traumatic; 2 months for non-traumatic Non-critical organ – wait is shorter before the DOAC could be restarted GI: 1-3 weeksNose, urinary tract: 1 week Have other risk factors for bleeding been removed or managed? Hypertension? Renal or liver disease? Non-mandatory anti-platelet agents or NSAIDs? P-gp or CYP3A4 inhibitors (antifungal azoles, dronedarone, amiodarone, verapamil, diltiazem)? Local bleeding sources (aneurysms, polyps, ulcers, etc.)?

 

References:

  1. Majeed A, Kim Y, Holmström M, Roberts RS, Schulman S. Optimal timing of resumption of warfarin after intracranial hemorrhage. Stroke. 2010;41:2860-2866.
  2. Majeed A, Wallvik N, Eriksson J, Hoijer J, Bottai M, Holmström M, Schulman S. Optimal timing of vitamin K antagonist resumption after upper gastrointestinal bleeding. A risk modelling analysis. Thromb Haemost. 2017;117:491-499.
  3. Pennlert J, Overholser R, Asplund K, et al. Optimal timing of anticoagulant treatment after intracerebral hemorrhage in patients with atrial fibrillation. Stroke. 2017;48:314-320.
  4. Schulman S. Bleeding Complications and Management on anticoagulant therapy. Semin Thromb Hemost. 2017;43:886-892.
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding