title: Reversal of Anticoagulation and Management of Bleeding in Patients on Anticoagulants.
abstract: Bleeding is the most common complication of all anticoagulants. Any bleeding patient on an anticoagulant should be risk-stratified based on hemodynamic instability, source of bleeding, and degree of blood loss. Although minor bleed may be managed with discontinuation of anticoagulant, major bleed may require transfusion of blood products and use of specific antidote. The residual effects of each anticoagulant may be monitored with distinct coagulation assay. Intravenous or oral vitamin K can reverse the effect of warfarin within 24 to 48 hours and is indicated for any bleeding, international normalized ratio of >10 or 4.5 to 10 in patients with other risk factors for bleeding. Fresh frozen plasma or prothrombin complex concentrate (PCC) may be necessary in major bleeding related to warfarin. Protamine sulfate reverses the effect of unfractionated heparin completely and of low-molecular-weight heparin (LMWH) partially. Idarucizumab has recently been approved in United States for dabigatran reversal, whereas andexanet alfa is expected to get approved in the near future for reversal of oral factor Xa inhibitors. The PCC may reverse the effect of rivaroxaban to some extent, but no data are available regarding reversal of apixaban and edoxaban. Aripazine has shown promising results to reverse the effects of LMWH, fondaparinux, and direct oral anticoagulants but is still in the developmental phase.
authors: 1 Department of Medicine, Michigan State University, East Lansing, MI, USA.
authors: Prajwal
authors: P
authors: Dhakal
authors: 1 Department of Medicine, Michigan State University, East Lansing, MI, USA.
authors: Supratik
authors: S
authors: Rayamajhi
authors: 2 Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
authors: Vivek
authors: V
authors: Verma
authors: 3 Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
authors: Krishna
authors: K
authors: Gundabolu
authors: 3 Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
authors: Vijaya R
authors: VR
authors: Bhatt
mesh_terms: D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D000931:Antidotes / Q000627:therapeutic use*; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D001780:Blood Coagulation Tests; D006470:Hemorrhage / Q000097:blood / Q000139:chemically induced / Q000628:therapy; D006801:Humans; D019934:International Normalized Ratio; D010949:Plasma; D011479:Protamines / Q000627:therapeutic use*
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000925:Anticoagulants; D000931:Antidotes; D001779:Blood Coagulation Factors; D011479:Protamines; C025667:prothrombin complex concentrates; C000594745:idarucizumab
keywords: anticoagulants; antidote; bleeding; reversal