Reversal of direct oral anticoagulants: Highlights from the Anticoagulation Forum guideline

Article Figures & Data

TABLE 1

Approved indications for direct oral anticoagulants

	Nonvalvular atrial fibrillation	Treatment of deep vein thrombosis or pulmonary embolism	Prevention of deep vein thrombosis in total knee replacement	Prevention of deep vein thrombosis in total hip replacement	Prevention of deep vein thrombosis in medically ill	Coronary artery disease or peripheral artery disease
Apixaban	Yes	Yes	Yes	Yes	No	No
Betrixaban	No	No	No	No	Yes	No
Dabigatran	Yes	Yes	No	Yes	No	No
Edoxaban	Yes	Yes	No	No	No	No
Rivaroxaban	Yes	Yes	Yes	Yes	No	Yes

TABLE 2

When to give high vs low dose andexanet alfa infusion

↵a Low dose: 400 mg intravenous bolus at a target rate of 30 mg/minute, followed by 4 mg/minute for up to 120 minutes.
↵b High dose: 800 mg intravenous bolus at a target rate of 30 mg/minute, followed by 8 mg/minute for up to 120 minutes.

TABLE 3

Reversal agents for dabigatran-, edoxaban- and betrixaban-related major bleeding or a required urgent procedure

DOAC	Reversal agent dosing
Dabigatran	Idarucizumab 5 g intravenously (IV) If idarucizumab is not available, the alternative treatment recommended is activated prothrombin complex concentrate 50 units/kg IV (off-label use)
Edoxaban, betrixaban	Andexanet alfa 800 mg IV bolus at 30 mg/minute followed by continuous infusion of 8 mg/minute for up to 120 minutes (off-label use) or 4-factor prothrombin complex concentrate 2,000 units IV

TABLE 4

Dosing of antifibrinolytic agents

Tranexamic acid	1–1.5 g orally every 8–12 hours for duration of bleeding
	10-20 mg/kg intravenous (IV) bolus followed by 10 mg/kg IV every 6–8 hours for major bleeding, hemophilic bleeding, or after major trauma
	Longer intervals for renal insufficiency

Epsilon-aminocaproic acid	3 g orally 3–4 times per day
	2 g IV every 6 hours or 1 g IV every hour, depending on the urgency

Desmopressin	0.3 μg/kg subcutaneously
	0.3 μg/kg IV in 50 mL of normal saline over 15–30 minutes