title: Management of the bleeding patient receiving new oral anticoagulants: a role for prothrombin complex concentrates.
abstract: Ease of dosing and simplicity of monitoring make new oral anticoagulants an attractive therapy in a growing range of clinical conditions. However, newer oral anticoagulants interact with the coagulation cascade in different ways than traditional warfarin therapy. Replacement of clotting factors will not reverse the effects of dabigatran, rivaroxaban, or apixaban. Currently, antidotes for these drugs are not widely available. Fortunately, withholding the anticoagulant and dialysis are freqnently effective treatments, particularly with rivaroxaban and dabigatran. Emergent bleeding, however, requires utilization of Prothrombin Complex Concentrates (PCCs). PCCs, in addition to recombinant factor VIIa, are used to activate the clotting system to reverse the effects of the new oral anticoagulants. In cases of refractory or emergent bleeding, the recommended factor concentrate in our protocols differs between the new oral anticoagulants. In patients taking dabigatran, we administer an activated PCC (aPCC) [FELBA] due to reported benefit in human in vitro studies. Based on human clinical trial evidence, the 4-factor PCC (Kcentra) is suggested for patients with refractory rivaroxaban- or apixaban-associated hemorrhage. If bleeding continues, recombinant factor VIIa may be employed. With all of these new procoagulant agents, the risk of thrombosis associated with administration of factor concentrates must be weighed against the relative risk of hemorrhage.
authors.affiliation: University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Baumann Kreuziger
authors.affiliation: University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Keenan
authors.affiliation: Regions Hospital, University of Minnesota, 640 Jackson Street, No. 11503C, Saint Paul, MN 55101, USA.
authors.forename: Colleen T
authors.initials: CT
authors.lastname: Morton
authors.affiliation: Regions Hospital, University of Minnesota, 640 Jackson Street, No. 11503C, Saint Paul, MN 55101, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Dries
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D001562:Benzimidazoles / Q000009:adverse effects* / Q000627:therapeutic use; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D002986:Clinical Trials as Topic; D000069604:Dabigatran; D015942:Factor VIIa / Q000627:therapeutic use; D006470:Hemorrhage / Q000139:chemically induced* / Q000188:drug therapy*; D006801:Humans; D011720:Pyrazoles / Q000009:adverse effects* / Q000627:therapeutic use; D011728:Pyridones / Q000009:adverse effects* / Q000627:therapeutic use; D012307:Risk Factors; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D001779:Blood Coagulation Factors; D011720:Pyrazoles; D011728:Pyridones; D015091:beta-Alanine; C025667:prothrombin complex concentrates; C522181:apixaban; D015942:Factor VIIa; D000069604:Dabigatran