Fig. 2.
Management strategies for patients bleeding who have received the novel oral anticoagulation agents. In cases of mild bleeding, stopping or delaying the next dose should be considered. The new agents including dabigatran, rivaroxaban, and recently approved apixiban have relatively short half-lives, so stopping the drug in patients with normal renal function, the anticoagulant effect rapidly decreases compared to warfarin. In patients with moderate to severe bleeding, standard therapeutic approaches should be considered, including supportive care that includes volume resuscitation, hemodynamic support with vasoactive therapy, blood product transfusions as determined by testing, and identification of bleeding source that may require surgical or another intervention. If the agents were taken within ≈2 h of admission, administration of oral activated charcoal should be considered. For dabigatran,† hemodialysis can remove ≈60% of the drug after several hours of dialysis and should be considered in patients with impaired renal function who are bleeding and will have altered clearance. Apixaban and rivaroxaban are highly protein bound and will not be cleared by hemodialysis. However, emergency access for hemodialysis requires vascular access with large bore catheters that may pose additional risk in the anticoagulated patient. For patients with life-threatening bleeding, hemodynamic and hemostatic resuscitation should be considered, with therapy similar to that for a trauma patient including the use of a massive transfusion protocol. Based on current data as discussed in the manuscript, the use of either three-factor or four-factor prothrombin complex concentrates (PCCs) depending on their availability should be considered as they have been shown to reverse or partially reverse the anticoagulation effect of the newer agents. ‡ In patients receiving dabigatran, the use of an activated PCC may be more effective. † However, there are no studies reporting the use of PCCs on actual bleeding in patients, and further studies including the development of specific reversal agents are underway currently. In hypotensive patients, hemodialysis is unlikely to be tolerated, and alternate methods for hemofiltration should be considered if needed. † The use of recombinant activated factor VIIa (rVIIa) decreases bleeding times in animal models, but there are no human studies to determine if this is effective. † = for dabigatran. ‡ = for rivaroxaban and apixiban.