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NOACS and bleeding
The document outlines key terminology related to novel oral anticoagulants (NOACs), direct oral anticoagulants (DOACs), and their management during bleeding events. It details protocols for preventing and treating bleeding, including the reversal of dabigatran and factor Xa inhibitors, with specific instructions for resuming anticoagulant therapy. The document emphasizes the importance of patient evaluation and laboratory monitoring in managing anticoagulation therapy and addressing bleeding complications.
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NOACS and bleeding
- 1.
- 2. Terminology • NOAC – Noveloral anticoagulants – Non VKA oral anticoagulants – (NO Anticoagulation) • DOAC – Direct oral anticoagulants
- 3.
- 5. • ODI – OralDirect Inhibitors • SODA – Specific Oral Direct Anticoagulant • TSOAC – Target Specific Oral Anticoagulant
- 6. Vote 2014 • DOAC29.9% • NOAC 28.6% • TSOAC 23.4% • North America and European • Australasia not asked to participate
- 10. New anticoagulants Direct ThrombinInhibitors - Dabigatran Factor Xa Inhibitors - Rivaroxaban - Apixaban - Edoxaban
- 20. Management of Bleeding •Prevention • Treatment
- 21. Prevention of Bleeding •Anticoagulant Selection • Patient and Dose Selection • Management of Interruption of Treatment
- 24. -5 -4 -3-2 -1 OR 1 2 3 4 5 6 DAYS “No”: DVT prophylaxis with LMWH or prophylacti c dose of NOAC Post -Procedure Use of NOACs Restart NOAC at therapeutic doses “Yes”: Restart NOAC at therapeutic doses Ask yourself: “Is it OK that the patient be fully anticoagulated 2 hours after 1st dose?” 1 3 “No” Delay restart of DOAC at therapeutic doses 2
- 29. Reversal of NOACs •Remove Drug • Active coagulation to overcome drug effect • Neutralise drug
- 32.
- 38. Patients received 5g of intravenous idarucizumab, which was administered as two 50-ml bolus infusions, each containing 2.5 g of idarucizumab, no more than 15 minutes apart. The 5-g dose was calculated to reverse the total body load of dabigatran that was associated with the 99th percentile of the dabigatran levels measured in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. *Pollack C, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015; 373:511-520.
- 39.
- 45. • Cost- 5gis $US3500 (wholesale)
- 46. *Siegal DM, etal. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015; 373:2413-2424.
- 54. ANNEXA-4 • Phase III •270 expected to be recruited • Jan 2015 to Nov 2022
- 57. Local hemostatic measures Hold1 or more doses of dabigatran Mild bleeding Moderate-severe Bleeding* Life-threatening Bleeding* Manage bleeding (compression, surgery) Fluid diuresis Transfuse RBCs or platelets if needed Oral charcoal if dose <2 hrs before If aPTT >40 sec, consult TE or Transfusion Medicine When was last dose? FBE, creatinine aPTT, TT (dTT) Patient with bleeding on dabigatran Contact Transfusion Medicine Tranexamic acid (1 G IV followed by 1 G infusion over 8 hours) Hemodialysis might be helpful Consider FEIBA* *
- 59. Local hemostatic measures Hold1 or more doses of drug Mild bleeding Moderate-severe Bleeding* Life-threatening Bleeding* Manage bleeding (compression, surgery) Fluid diuresis Transfuse RBCs or platelets if needed Oral charcoal if dose <2 hrs before If abnormal, consult TE or Transfusion Medicine When was last dose? FBE, creatinine INR/anti-Xa level Patient with bleeding on rivaroxaban/apixaban Contact Transfusion Medicine Tranexamic acid (1 G IV followed by 1 G infusion over 8 hours) Consider FEIBA*/PCC
- 60.
Editor's Notes
- #25 24