title: Managing reversal of direct oral anticoagulants in emergency situations. Anticoagulation Education Task Force White Paper.
abstract: 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.
authors.affiliation: Walter Ageno, MD, University of Insubria, Varese, Italy, E-mail: agewal@yahoo.com.
authors.forename: Walter
authors.initials: W
authors.lastname: Ageno
authors.forename: Harry R
authors.initials: HR
authors.lastname: Büller
authors.forename: Anna
authors.initials: A
authors.lastname: Falanga
authors.forename: Werner
authors.initials: W
authors.lastname: Hacke
authors.forename: Jeroen
authors.initials: J
authors.lastname: Hendriks
authors.forename: Trudie
authors.initials: T
authors.lastname: Lobban
authors.forename: Jose
authors.initials: J
authors.lastname: Merino
authors.forename: Ivan S
authors.initials: IS
authors.lastname: Milojevic
authors.forename: Francisco
authors.initials: F
authors.lastname: Moya
authors.forename: H Bart
authors.initials: HB
authors.lastname: van der Worp
authors.forename: Gary
authors.initials: G
authors.lastname: Randall
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Tsioufis
authors.forename: Peter
authors.initials: P
authors.lastname: Verhamme
authors.forename: A John
authors.initials: AJ
authors.lastname: Camm
mesh_terms: D000284:Administration, Oral; D026683:Advisory Committees; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D000925:Anticoagulants / Q000009:adverse effects*; D000069604:Dabigatran; D065427:Factor Xa Inhibitors; D006470:Hemorrhage / Q000188:drug therapy*; D006801:Humans; D000069552:Rivaroxaban
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000925:Anticoagulants; D065427:Factor Xa Inhibitors; C000594745:idarucizumab; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: Anticoagulation; atrial fibrillation; reversal agents; stroke prevention; venous thromboembolism