Review: managing the bleeding patient on one of the new anticoagulants

October 24, 2013, 1:58 am


Management of bleeding and reversal strategies for oral anticoagulants: Clinical practice considerations. Nutescu EA et al. Am J Health-Syst Pharm 2013 Nov 1;70:1914-29.


This long review article —presenting consensus recommendations of an “expert” panel — is seriously hampered by the fact that there are not many clinical, or even laboratory, studies of reversing the anticoagulation effects of dabigatran (Pradaxa), Rivaroxaban (Xarelto), and apixaban (Eliquis).

Therefore, reading the paper is a very frustrating slog, as one tries to pan clinical nuggets from the rushing stream of unhelpful generalities. As the authors admit, there are limited data and large gaps in our knowledge. The paper contains frequent variations of the phrase I hate most in the medical literature, “could be considered”. Thus:

Clinicians could consider administering small doses of aPCC (e.g., 8-10 units/kg){ immediately before the insertion of dialysis catheters or other invasive procedures in patients receiving dabigatran, as life-threatening bleeding could develop.

Well, anything could be considered. If the authors are recommending this, they should say so. If they are leaving it up to the individual clinician — who probably knows less about these agents than they do — the patient may expire while the physician is considering the best course of action.

There are a few clinical pearls I found helpful:

  • Dabigatran, which is only 35% protein-bound, is dialyzable.
  • The direct factor Xa inhibitors rivaroxaban and apixaban are approximately 90% protein-bound, and thus unlikely to be dialyzable.
  • While new anticoagulants such as dabigatran are touted as having fewer drug interactions as does warfarin, there are still many drugs that can affect its pharmacokinetics and pharmacodynamics.

Probably the two best recommendations in the paper are:

  1. Anticipate and avoid problems by carefully evaluating factors that can impact the effect of the drug (e.g., significant renal failure in the case of dabigatran)
  2. Calling on representatives from relevant departments — emergency, trauma surgery, hematology, nephrology, pharmacy, nursing, etc. — develop in advance a plan for dealing with patients on these agents who present with significant bleeding or need reversal of anticoagulation for emergent procedures.

Related posts:

Massive bleeding associated with dabigatran

Case report: hemodialysis for dabigatran overdose

The many potential problems with using dabigatran

New York times on dabigatran

Case series: four patients with dabigatran-associated bleeding

Guidelines for reversing overdose of dabigatran (Pradaxa) and other new anticoagulants

Care Report: fatal GI bleed 6 days after one dose of dabigatran (Pradaxa)

Dabigatran: is laboratory monitoring really unnecessary?

Dabiagtran and the trauma patient

Dabigatran Toxicity: The Top 10 Questions

Review: the bleeding patient on dabigatran

Dabigatran and the elderly

Dabigatran etexilate: a new challenge for emergency physicians and toxicologists






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