What Does the ACC Say About OAC Reversal?

Just in case you were curious ….

Conventional tests useful for ruling out clinically relevant levels contributing to bleeding risk:

  • Dabigatran – a normal Thrombin Time or sensitive activated partial thromboplastin time (aPTT).
  • Factor Xa-inhibitors – None.

If you have access to Anti-Xa specialized assays, they can be used to measure the level of activity for the Factor Xa-inhibitors.

Managing OAC-associated bleeding:

  • Warfarin – 4-factor prothrombin concentrate complexes (PCCs) at weight-based dosing between 25 units/kg and 50 units/kg based on INR.
  • Dabigatran – Idarucizumab.
  • Factor Xa-inhibitors – 4-factor PCCs at 50 units/kg.

The authors also suggest use of PCCs as second line for idarucizumab, but this is likely to be fruitless and the evidence is very weak. Hemodialysis is also an option for removal of circulating dabigatran in a narrow set of clinical scenarios.

The authors also mention andexanet alfa and ciraparantag as potentially useful adjuncts at some point in the future, but no specific clinical role has yet been defined.

“2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants”