title: Developing a management plan for oral anticoagulant reversal.
abstract: OBJECTIVE
  To describe a process for prompt evaluation and management- including reversal of the effects of warfarin and target-specific oral anticoagulants-of patients with or at high risk for bleeding during oral anticoagulant therapy or when such therapy is interrupted for an urgent invasive procedure or surgery.
  
  
  CONCLUSIONS
  The use of pharmacologic interventions for anticoagulant reversal may depend on the measured level of anticoagulation, time since the last anticoagulant dose, target level of coagulation, reliability of laboratory tests of coagulation, severity of or risk for bleeding, the agents' mechanism of action and pharmacokinetics, and pharmacodynamics of the reversal agent. The patient's age, weight, renal function, comorbid conditions, and other drug therapy, as well as the risk for thromboembolism and other adverse effects of the reversal therapies, also enter into therapeutic decisions. Hemodialysis may be used to remove the direct thrombin (factor IIa) inhibitor dabigatran and reverse its anticoagulant effects. Limited experience with clotting factor concentrates suggests that activated prothrombin complex concentrate may be useful for reversing the anticoagulant effects of dabigatran. The activity of oral factor Xa inhibitors (i.e., rivaroxaban and apixaban) is higher up the common pathway of the coagulation cascade and thus may be easier to reverse than that of direct thrombin inhibitors. Additional clinical experience is needed to identify the optimal reversal agents, dosage, and impact on thrombosis or bleeding outcomes for both classes of agents.
  
  
  CONCLUSIONS
  A comprehensive plan individualized to each agent should be developed to promptly reverse the effects of oral anticoagulants and optimize outcomes in patients with bleeding or an urgent need for surgery.
authors: University of California (UC) Davis Medical Center, Sacramento, CA 95817, USA. william.dager@ucdmc.ucdavis.edu
authors: William E
authors: WE
authors: Dager
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects* / Q000037:antagonists & inhibitors*; D000933:Antifibrinolytic Agents / Q000627:therapeutic use*; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D004630:Emergencies; D006470:Hemorrhage / Q000139:chemically induced / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D006801:Humans; D006435:Renal Dialysis / Q000379:methods; D018570:Risk Assessment; D012307:Risk Factors; D013514:Surgical Procedures, Operative; D016896:Treatment Outcome; D010837:Vitamin K 1 / Q000627:therapeutic use*; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects* / Q000037:antagonists & inhibitors*
chemical_list: D000925:Anticoagulants; D000933:Antifibrinolytic Agents; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates; D014859:Warfarin; D010837:Vitamin K 1