title: Re-initiation of dabigatran and direct factor Xa antagonists after a major bleed.
abstract: Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient's risk of thromboembolism must be balanced with the risk of recurrent major bleeding. This review provides guidance for clinicians regarding if and when a patient should be re-initiated on DOAC therapy following a major hemorrhage, based on the existing evidence.
authors.affiliation: Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX. Electronic address: TMilling@seton.org.
authors.forename: Truman J
authors.initials: TJ
authors.lastname: Milling
authors.affiliation: Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, Manhasset, NY.
authors.forename: Alex C
authors.initials: AC
authors.lastname: Spyropoulos
mesh_terms: D000991:Antithrombins / Q000008:administration & dosage* / Q000009:adverse effects; D000066491:Clinical Decision-Making; D000069604:Dabigatran / Q000008:administration & dosage* / Q000009:adverse effects; D065427:Factor Xa Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced*; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D013923:Thromboembolism / Q000517:prevention & control*
chemical_list: D000991:Antithrombins; D065427:Factor Xa Inhibitors; D000069604:Dabigatran