Managing reversal of direct oral anticoagulants in emergency situations

Walter Ageno; Harry R. Büller; Anna Falanga; Werner Hacke; Jeroen Hendriks; Trudie Lobban; Jose Merino; Ivan S. Milojevic; Francisco Moya; H. Bart van der Worp; Gary Randall; Konstantinos Tsioufis; Peter Verhamme; A. John Camm

doi:10.1160/TH16-05-0363

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2016; 116(06): 1003-1010
DOI: 10.1160/TH16-05-0363

Anticoagulation Education Task Force White Paper

Schattauer Publishers Schattauer

Managing reversal of direct oral anticoagulants in emergency situations

Anticoagulation Education Task Force White Paper

Walter Ageno

¹University of Insubria, Varese, Italy

,

Harry R. Büller

²Academic Medical Centre, Amsterdam, The Netherlands

,

Anna Falanga

³Department of Immunohematology & Transfusion Medicine and the Hemostasis and Thrombosis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy

,

Werner Hacke

⁴Department of Neurology, Heidelberg University, Heidelberg, Germany

,

Jeroen Hendriks

⁵Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, South Australian Health & Medical Research Institute, Adelaide, Australia

⁶Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

,

Trudie Lobban

⁷Arrhythmia Alliance and AF Association, Hampshire, UK

,

Jose Merino

⁸Arrhythmia Research Unit, Universitario La Paz , Madrid, Spain

,

Ivan S. Milojevic

⁹General Hospital Cuprija, Cuprija, Serbia

,

Francisco Moya

¹⁰International Medical Services and Emergency Medicine, Vithas-Xanit International Hospital, Benalmadena, Malaga, Spain

,

H. Bart van der Worp

¹¹Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands

,

Gary Randall

¹²Stroke Alliance For Europe (SAFE), London, UK

,

Konstantinos Tsioufis

¹³First Cardiology Clinic, Hippokration Hospital, University of Athens, Greece

,

Peter Verhamme

¹⁴University of Leuven, Leuven, Belgium

,

A. John Camm

¹⁵Division of Cardiovascular Sciences, St George’s University of London, London, UK

¹⁶ICMS, Imperial College, London, UK

› Author Affiliations

Abstract

Summary

Anticoagulation is the cornerstone of prevention and treatment of venous thromboembolism (VTE) and stroke prevention in patients with atrial fibrillation (AF). However, the mechanisms by which anticoagulants confer therapeutic benefit also increase the risk of bleeding. As such, reversal strategies are critical. Until recently, the direct oral anticoagulants (DOACs) dabigatran, rivaroxaban, apixaban, and edoxaban lacked a specific reversal agent. This report is based on findings from the Anticoagulation Education Task Force, which brought together patient groups and professionals representing different medical specialties with an interest in patient safety and expertise in AF, VTE, stroke, anticoagulation, and reversal agents, to discuss the current status of anticoagulation reversal and fundamental changes in management of bleeding associated with DOACs occasioned by the approval of idarucizumab, a specific reversal agent for dabigatran, as well as recent clinical data on specific reversal agents for factor Xa inhibitors. Recommendations are given for when there is a definite need for a reversal agent (e.g. in cases of life-threatening bleeding, bleeding into a closed space or organ, persistent bleeding despite local haemostatic measures, and need for urgent interventions and/or interventions that carry a high risk for bleeding), when reversal agents may be helpful, and when a reversal agent is generally not needed. Key stakeholders who require 24–7/around-the-clock access to these agents vary among hospitals; however, from a practical perspective the emergency department is recommended as an appropriate location for these agents. Clearly, the advent of new agents requires standardised protocols for treating bleeding on an institutional level.

Keywords

Anticoagulation - venous thromboembolism - stroke prevention - atrial fibrillation - reversal agents

Full Text

References

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