How can we reverse bleeding in patients on direct oral anticoagulants?

Abstract

The direct oral anticoagulants (DOACs), or non-vitamin K antagonist oral anticoagulants (NOACs), including dabigatran, which inhibits thrombin, as well as rivaroxaban, apixaban, edoxaban, and betrixaban, which inhibit coagulation factor Xa, are as­sociated with similar or lower risk of bleeding compared with warfarin. The need for reversal of their anticoagulant effect may occur in patients with life-threatening bleeding or those requiring urgent surgery. Currently, the only specific reversal agent for dabigatran, idarucizumab, is widely available, while andexanet alfa, which reverses factor Xa inhibitors, was approved in the United States in May 2018. Ciraparantag, which has been designed to reverse all DOACs and other anticoagulants, is being investigated in clinical trials. In the absence of licensed reversal agents for the oral factor Xa inhibitors, prothrombin complex concentrates are suggested in patients with life-threatening bleeding. Vitamin K and fresh frozen plasma should not be used to reverse DOACs. This review presents the current evidence regarding bleeding risk on DOACs and the reversal strategies to provide guidance on the management of patients treated with DOACs, who experience serious bleeding.