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Management of the bleeding patient receiving new oral anticoagulants: a role for prothrombin complex concentrates.

Baumann Kreuziger LM, Keenan JC, Morton CT, Dries DJ - Biomed Res Int (2014)

Bottom Line: Fortunately, withholding the anticoagulant and dialysis are freqnently effective treatments, particularly with rivaroxaban and dabigatran.PCCs, in addition to recombinant factor VIIa, are used to activate the clotting system to reverse the effects of the new oral anticoagulants.In patients taking dabigatran, we administer an activated PCC (aPCC) [FELBA] due to reported benefit in human in vitro studies.

View Article: PubMed Central - PubMed

Affiliation: University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.

ABSTRACT
Ease of dosing and simplicity of monitoring make new oral anticoagulants an attractive therapy in a growing range of clinical conditions. However, newer oral anticoagulants interact with the coagulation cascade in different ways than traditional warfarin therapy. Replacement of clotting factors will not reverse the effects of dabigatran, rivaroxaban, or apixaban. Currently, antidotes for these drugs are not widely available. Fortunately, withholding the anticoagulant and dialysis are freqnently effective treatments, particularly with rivaroxaban and dabigatran. Emergent bleeding, however, requires utilization of Prothrombin Complex Concentrates (PCCs). PCCs, in addition to recombinant factor VIIa, are used to activate the clotting system to reverse the effects of the new oral anticoagulants. In cases of refractory or emergent bleeding, the recommended factor concentrate in our protocols differs between the new oral anticoagulants. In patients taking dabigatran, we administer an activated PCC (aPCC) [FELBA] due to reported benefit in human in vitro studies. Based on human clinical trial evidence, the 4-factor PCC (Kcentra) is suggested for patients with refractory rivaroxaban- or apixaban-associated hemorrhage. If bleeding continues, recombinant factor VIIa may be employed. With all of these new procoagulant agents, the risk of thrombosis associated with administration of factor concentrates must be weighed against the relative risk of hemorrhage.

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Management protocol for hemorrhage in patients taking dabigatran, rivaroxaban, or apixaban.
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fig1: Management protocol for hemorrhage in patients taking dabigatran, rivaroxaban, or apixaban.

Mentions: Our institution has created protocols to help direct the use of factor concentrates in the treatment of life threatening bleeding in patients taking new oral anticoagulants (Figure 1). The initial measures are the same for any bleeding patient, with local intervention and supportive care. In addition, confirmation of medication, dosing, and duration since the last dose guides further therapy. Renal and hepatic function are evaluated to determine patient metabolism of medication. Transfusion of packed RBCs and a transfusion protocol featuring a balance of packed red blood cells, plasma, and platelets may be utilized depending on the severity of hemorrhage. Based largely on retrospective data, the optimal ratio of plasma to packed RBCs administered is thought to be 1 : 1 or 1 : 2 [24]. The effects of antiplatelet agents are reversed by transfusion of 2 apheresis units of platelet concentrates if needed (see below) [25, 26].


Management of the bleeding patient receiving new oral anticoagulants: a role for prothrombin complex concentrates.

Baumann Kreuziger LM, Keenan JC, Morton CT, Dries DJ - Biomed Res Int (2014)

Management protocol for hemorrhage in patients taking dabigatran, rivaroxaban, or apixaban.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4127295&req=5

fig1: Management protocol for hemorrhage in patients taking dabigatran, rivaroxaban, or apixaban.
Mentions: Our institution has created protocols to help direct the use of factor concentrates in the treatment of life threatening bleeding in patients taking new oral anticoagulants (Figure 1). The initial measures are the same for any bleeding patient, with local intervention and supportive care. In addition, confirmation of medication, dosing, and duration since the last dose guides further therapy. Renal and hepatic function are evaluated to determine patient metabolism of medication. Transfusion of packed RBCs and a transfusion protocol featuring a balance of packed red blood cells, plasma, and platelets may be utilized depending on the severity of hemorrhage. Based largely on retrospective data, the optimal ratio of plasma to packed RBCs administered is thought to be 1 : 1 or 1 : 2 [24]. The effects of antiplatelet agents are reversed by transfusion of 2 apheresis units of platelet concentrates if needed (see below) [25, 26].

Bottom Line: Fortunately, withholding the anticoagulant and dialysis are freqnently effective treatments, particularly with rivaroxaban and dabigatran.PCCs, in addition to recombinant factor VIIa, are used to activate the clotting system to reverse the effects of the new oral anticoagulants.In patients taking dabigatran, we administer an activated PCC (aPCC) [FELBA] due to reported benefit in human in vitro studies.

View Article: PubMed Central - PubMed

Affiliation: University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.

ABSTRACT
Ease of dosing and simplicity of monitoring make new oral anticoagulants an attractive therapy in a growing range of clinical conditions. However, newer oral anticoagulants interact with the coagulation cascade in different ways than traditional warfarin therapy. Replacement of clotting factors will not reverse the effects of dabigatran, rivaroxaban, or apixaban. Currently, antidotes for these drugs are not widely available. Fortunately, withholding the anticoagulant and dialysis are freqnently effective treatments, particularly with rivaroxaban and dabigatran. Emergent bleeding, however, requires utilization of Prothrombin Complex Concentrates (PCCs). PCCs, in addition to recombinant factor VIIa, are used to activate the clotting system to reverse the effects of the new oral anticoagulants. In cases of refractory or emergent bleeding, the recommended factor concentrate in our protocols differs between the new oral anticoagulants. In patients taking dabigatran, we administer an activated PCC (aPCC) [FELBA] due to reported benefit in human in vitro studies. Based on human clinical trial evidence, the 4-factor PCC (Kcentra) is suggested for patients with refractory rivaroxaban- or apixaban-associated hemorrhage. If bleeding continues, recombinant factor VIIa may be employed. With all of these new procoagulant agents, the risk of thrombosis associated with administration of factor concentrates must be weighed against the relative risk of hemorrhage.

Show MeSH
Related in: MedlinePlus