title: Management of bleeding in patients receiving non-vitamin K antagonists.
abstract: Anticoagulation with non-vitamin K antagonists (Non vitamin K oral anticoagulant (NOACs)) including dabigatran, rivaroxaban, apixaban and edoxaban is at least as effective as warfarin, has fewer drug and food interactions and does not require monthly monitoring. Although major bleeding with NOACs is infrequent, there remains concern about the ability to effectively treat episodes of major bleeding. New agents have been developed that are capable of providing rapid reversal of the anticoagulation effect of NOACs. Idarucizumab normalises the dilute thrombin time and the ecarin clotting time, both of which are elevated with dabigatran. Andexanet alfa reduces increased anti-factor Xa activity seen with the use of rivaroxaban and apixaban. A universal reversal agent is in development. These agents, unlike agents to reverse the anticoagulation effect of vitamin K antagonists, appear to reverse the specific NOAC anticoagulant. The development of reversal agents is a major advancement in managing bleeding in the era of NOACs. Future studies will be required to determine the impact on important clinical outcomes.
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
authors.forename: Sudarshan
authors.initials: S
authors.lastname: Balla
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Koerber
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, University of Missouri-Columbia, Columbia, Missouri, USA.
authors.forename: Greg
authors.initials: G
authors.lastname: Flaker
mesh_terms: D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects*; D000069604:Dabigatran / Q000627:therapeutic use; D015951:Factor Xa / Q000627:therapeutic use; D065427:Factor Xa Inhibitors / Q000627:therapeutic use*; D006470:Hemorrhage / Q000188:drug therapy*; D006801:Humans; D011994:Recombinant Proteins / Q000627:therapeutic use; D016896:Treatment Outcome; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000925:Anticoagulants; D065427:Factor Xa Inhibitors; C580915:PRT064445; D011994:Recombinant Proteins; D014859:Warfarin; C000594745:idarucizumab; D015951:Factor Xa; D000069604:Dabigatran
keywords: DOACs; Major bleeding; NOACs; andexanet alfa; idarucizumab; non-vitamin K antagonist related bleeding