title: Bleeding complications from the direct oral anticoagulants.
abstract: BACKGROUND
  Direct oral anticoagulants (DOACs) are now standard of care for the management of thromboembolic risk. A prevalent issue of concern is how to manage direct oral anticoagulant (DOAC)-associated bleeding for which there is no specific antidote available for clinical use. We conducted a retrospective case series to describe the Toronto, Canada multicenter experience with bleeding from dabigatran or rivaroxaban.
  
  
  METHODS
  Retrospective chart review of DOAC bleeding necessitating referral to hematology and/or transfusion medicine services at five large University of Toronto affiliated academic hospitals from January 2011 to December 2013.
  
  
  RESULTS
  Twenty-six patients with DOAC bleeding were reviewed; 42 % bleeds intracranial and 50 %, gastrointestinal. All patients had at least one risk factor associated with DOAC bleeding reported in previous studies. Inconsistent bleed management strategies were evident. Median length of hospital stay was 11 days (1-90). Five thromboembolic events occurred after transfusion based-hemostatic therapy and there were six deaths.
  
  
  CONCLUSIONS
  Management of DOAC bleeding is variable. Clinical trial data regarding DOAC reversal is needed to facilitate optimization and standardization of bleeding treatment algorithms.
authors.affiliation: Division of Hematology, Department of Medicine and Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, University of Toronto, 30 Bond Street, Room 2-007G Core Lab, Carter Wing, Toronto, ON M5B-1 W8 Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Sholzberg
authors.affiliation: Division of Hematology, Department of Medicine and Department of Laboratory Medicine and Pathobiology St. Michael's Hospital, University of Toronto, Toronto, Ontario Canada.
authors.forename: Katerina
authors.initials: K
authors.lastname: Pavenski
authors.affiliation: Departments of Medicine and Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, Toronto, ON Canada.
authors.forename: Nadine
authors.initials: N
authors.lastname: Shehata
authors.affiliation: Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, ON Canada.
authors.forename: Christine
authors.initials: C
authors.lastname: Cserti-Gazdewich
authors.affiliation: Department of Clinical Pathology, Sunnybrook Health Sciences Centre; and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON Canada.
authors.forename: Yulia
authors.initials: Y
authors.lastname: Lin
keywords: Anticoagulants; Blood transfusion; Dabigatran; Hemorrhage; Rivaroxaban