This post contains a link to the section on Anticoagulation Reversal from the EM Cases Quick Hits*, September 2019.
*Helman, A. Swaminathan, A. Austin, E. Long, B. Rosenberg, H. Ho, M. Cheskes, S. EM Quick Hits 8 – Lemierre’s Disease, Clonidine Toxicity, Routine Coag Panel, Anticoagulation Reversal, Mechanical CPR. September, 2019. https://emergencymedicinecases.com/em-quick-hits-september-2019/. Accessed 9-30-2019.
The portion of the podcast on anticoagulation reversal is from 17:22 to 24:00.
Here are the show notes:
Anticoagulation Reversal: Review of CJEM’s ‘Just the Facts’ series
- Consider reversal of anticoagulation if there is a life-threatening or major bleed.
Reversal by anticoagulant:
- Warfarin: Vitamin K inhibitor
- An INR should guide reversal, unless there is an immediate life-threat requiring immediate reversal. PCC (Octaplex in Canada) combined with IV vitamin K* are the agents of choice.
- [Never push IV Vitamin K*]
- Make sure to repeat the INR 30 minutes and 6 hours post PCC dose.
*Appendix B: Phytadione (Vitamin K) Dosing Guidelines [PDF] 9-14-2009 from Johns Hopkins Medicine.
- Dabigatran: Factor IIa inhibitor
- If they have a normal aPTT there is likely not a large burden of dabigatran. If you are able to get a normal Thrombin time, this excludes dabigatran.
- For reversal, PCC is the main stay.
- Idarucizumab (Praxbind) is an agent available currently for reversal however it has not been studied compared to a control group. Its use is controversial but not unreasonable.
- Apixaban, Rivaroxaban, Edoxaban: Factor Xa inhibitors
- The only available agent for reversal in Canada is PCC. Studies with PCC do not have control groups.
- In the US Andexanet Alpha may reverse blood peramers, however it is very expensive, has a high risk of thrombosis and has not been shown to improve patient oriented outcomes. Therefore it is not currently recommended by our experts.
References from the show notes
- Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e44S-e88S.
- Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94(6):697-709.
- Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70(24):3042-3067.