Practical management of bleeding in patients receiving non-vitamin K antagonist oral anticoagulants

Jeffrey I. Weitz; Charles V. Pollack Jr

doi:10.1160/TH15-03-0222

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2015; 114(06): 1113-1126
DOI: 10.1160/TH15-03-0222

Review Article

Schattauer GmbH

Practical management of bleeding in patients receiving non-vitamin K antagonist oral anticoagulants

Authors

Jeffrey I. Weitz

¹McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
Charles V. Pollack Jr

²Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Abstract

Summary

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used in the prevention and treatment of venous thromboembolism and in the prevention of stroke in patients with non-valvular atrial fibrillation. In phase III clinical trials and meta-analyses, the NOACs were at least as effective as vitamin K antagonists (VKAs) and were associated with a similar or lower incidence of major bleeding, including consistent and significant decreases in intracranial bleeding, although with an increase in gastrointestinal bleeding for some agents compared with VKAs. Subsequent real-world evidence supports these outcomes. Despite this, physicians have concerns about serious bleeding or emergencies because there are no specific reversal agents for the NOACs. However, in clinical trials, patients receiving NOACs generally had similar or better outcomes after these events than those taking VKAs. As with any bleeding, anticoagulant-related bleeding should first be stratified according to severity and location; risk can be minimised by ongoing assessment. Management protocols for NOAC-related bleeding are similar to those for VKAs but should take into account the pharmacological profile of the specific drug. Because of their short half-lives, NOAC-related mild bleeding can often be controlled by temporarily withholding treatment. More severe bleeding requires standard escalating haemodynamic support measures, and non-specific reversal agents can be considered in life-threatening situations, based on limited clinical data. Specific and rapid reversal agents are not currently available for any oral anticoagulant and restoration of coagulation may not necessarily lead to better outcomes. Nevertheless, specific NOAC reversal agents are in development and show promise in healthy volunteers.

Keywords

Bleeding profiles - bleeding management - non-vitamin K oral anticoagulant - real-world data - reversal agent

Full Text

References

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