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

Top Questions on...

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.)?



  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