# How to Reverse Oral Anticoagulants

About This Podcast

The number of new oral anticoagulants has grown dramatically in the last few years. And with that growth has come the need for new reversal agents. Reversing anticoagulation in patients with acute intra-cranial hemorrhages can be complex and dependent on what medication your hospital stores. It is important to know what is out there, what you can use, and how effective it is likely to be.

Anticoagulation use is certainly not unique to older adults, but is much more common because of the higher prevalence of a-fib and the concurrently higher CHADS-VASC score, as well as higher rates of valvular disease and venous thromboembolism. Older adults are also at higher risk of intra-cranial hemorrhage even without anticoagulation. Putting the risks of age and the higher rates of anti-coagulation use makes anticoagulation reversal an important topic for the care of older patients.

In this episode Leah Hatfield, an ED pharmacist, and I discuss a hypothetical 70 year old female on a range of different anticoagulants who presents with a traumatic intra-parenchymal hemorrhage after a fall from standing.

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https://youtu.be/N41qoeoBHj4

Summary of Recommendations

For the thrombin inhibitors, Praxbind would be first line, and PCC may be tried, but may not be of benefit. However, PCC is effective in reversing the anticoagulant effect of the Xa inhibitor Rivaroxaban (see Eerenberg article listed below). It is important to note, however, that the study listed was on anticoagulant effect, not on patient outcomes. Most institutions will have an agreed-upon anticoagulation reversal protocol that incorporates the availability of the below items at your site. Second line agents in parentheses. This is presuming FDA approval of andexanet alpha occurs shortly!

Next, listen to the two-part series Eye Emergencies in the Elderly with Dr. Bryan Hong.

Play Part 1

Play Part 2

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References

Barnes GD, Kurtz B. Direct oral anticoagulants: Unique properties and practical approaches to management. Heart. 2016;102(20):1620-1626. https://www.ncbi.nlm.nih.gov/pubmed/27402803

Tummala R, Kavtaradze A, Gupta A, Ghosh RK. Specific antidotes against direct oral anticoagulants: A comprehensive review of clinical trials data. Int J Cardiol. 2016;214:292-298. https://www.ncbi.nlm.nih.gov/pubmed/27082776

Rogers KC, Shelton MP, Finks S. Reversal agents for direct oral anticoagulants: Understanding new and upcoming options. Cardiol Rev. 2016. https://www.ncbi.nlm.nih.gov/pubmed/27548686

Christos S, Naples R. Anticoagulation reversal and treatment strategies in major bleeding: Update 2016. West J Emerg Med. 2016;17(3):264-270. https://www.ncbi.nlm.nih.gov/pubmed/27330657

Jaben EA, Mulay SB, Stubbs JR. Reversing the effects of antiplatelet agents in the setting of intracranial hemorrhage: A look at the literature. J Intensive Care Med. 2015;30(1):3-7. https://www.ncbi.nlm.nih.gov/pubmed/25492811

Reddy S, Sharma R, Grotts J, Ferrigno L, Kaminski S. Incidence of intracranial hemorrhage and outcomes after ground-level falls in geriatric trauma patients taking preinjury anticoagulants and antiplatelet agents. Am Surg. 2014;80(10):975-978. https://www.ncbi.nlm.nih.gov/pubmed/25264642

Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-8.e1-7. https://www.ncbi.nlm.nih.gov/pubmed/22626015

Edavettal M, Rogers A, Rogers F, Horst M, Leng W. Prothrombin complex concentrate accelerates international normalized ratio reversal and diminishes the extension of intracranial hemorrhage in geriatric trauma patients. Am Surg. 2014;80(4):372-376. https://www.ncbi.nlm.nih.gov/pubmed/24887668

Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): A randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613. https://www.ncbi.nlm.nih.gov/pubmed/27178479

Eerenberg ES, Kamphuisen PW, Sijpkens MK, Meijers JC, Buller HR, Levi M ..Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation 2011; 124(14) https://www.ncbi.nlm.nih.gov/pubmed/21900088

Image credit [brain image].

This podcast uses sounds from freesound.org by Jobro and HerbertBoland

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