title: The Real-World Treatment of Hemorrhages Associated With Dabigatran and Rivaroxaban: A Multicenter Evaluation.
abstract: OBJECTIVE
  Adoption of the target-specific oral anticoagulants (TSOACs) has been slow; accordingly, lack of guidance for emergent reversal confounded by the need for "direct" reversal agents has contributed significantly to warfarin entrenchment in the medical community. The purpose of this analysis is to provide real-world experiences regarding the management of the hemorrhaging patient secondary to dabigatran and rivaroxaban.
  
  
  METHODS
  Retrospective review of patients admitted with a hemorrhage secondary to dabigatran or rivaroxaban were evaluated. Descriptive statistics were utilized for analysis.
  
  
  RESULTS
  Four hundred forty-four patients were screened for inclusion into the study; notably, 419 (94%) of the patients were excluded because the bleed was secondary to warfarin therapy. Of those included in this analysis (n = 25), gastrointestinal bleeding accounted for 21 events (84%), followed by intracranial (n = 2; 8%) and epistaxis (n = 2; 8%). Two patients (8%) expired during admission and 6 patients (24%) expired within 6 months after discharge from the hospital. Three (12%) minor bleeds, 7 (28%) major bleeds, and 15 (60%) life-threatening bleeds were identified. Minor bleeds required careful monitoring, supportive care, and cessation of anticoagulation therapy, whereas increasing severity required multiple interventions with prothrombin complex concentrate, recombinant activated factor 7, fresh frozen plasma, packed red blood cells, cryoprecipitate, and platelets.
  
  
  CONCLUSIONS
  The approach to the management of bleeding events borne from TSOACs has proven to be very heterogeneous. In the midst of this observation period, these facilities developed protocols, which created a stratification of bleeds and a more regimented approach to managing them. Although bleeding is less with new agents, the creation of pathways/algorithms for the management of TSOACs and education regarding clinical decision-making may be beneficial for the expeditious and appropriate management when these events arise.
authors.affiliation: From the *Pharmacy Practice Resident, Centennial Medical Center, 2300 Patterson Street, Nashville, TN 37203; †Clinical Pharmacy Specialist, Cardiology, TriStar Centennial Medical Center, 2300 Patterson Street, Nashville, TN 37203; and ‡ Clinical Pharmacy Specialist, Cardiology, Roper Hospital, 316 Calhoun Street, Charleston, SC 29401.
authors.forename: Lesley
authors.initials: L
authors.lastname: Pahs
authors.forename: Craig
authors.initials: C
authors.lastname: Beavers
authors.forename: Patricia
authors.initials: P
authors.lastname: Schuler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000991:Antithrombins / Q000009:adverse effects*; D001779:Blood Coagulation Factors / Q000627:therapeutic use; D003029:Coagulants / Q000627:therapeutic use*; D015331:Cohort Studies; D000069604:Dabigatran / Q000009:adverse effects*; D004844:Epistaxis / Q000139:chemically induced / Q000628:therapy*; D017707:Erythrocyte Transfusion; D005169:Factor VIII / Q000627:therapeutic use; D015942:Factor VIIa / Q000627:therapeutic use; D005260:Female; D005340:Fibrinogen / Q000627:therapeutic use; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced / Q000628:therapy*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010949:Plasma; D017713:Platelet Transfusion; D011994:Recombinant Proteins; D012189:Retrospective Studies; D000069552:Rivaroxaban / Q000009:adverse effects*
chemical_list: D000991:Antithrombins; D001779:Blood Coagulation Factors; D003029:Coagulants; D011994:Recombinant Proteins; C026912:cryoprecipitate coagulum; C025667:prothrombin complex concentrates; D005169:Factor VIII; D005340:Fibrinogen; D000069552:Rivaroxaban; D015942:Factor VIIa; D000069604:Dabigatran