Today I want to talk about anticoagulation reversal. I happened to be on Northside when a patient on dabigatran had an unwitnessed fall with some minor head trauma and got me thinking about my reversal agents, and here's the POTD.
First it’s worth mentioning when to reverse anticoagulation. The first step to looking at anticoagulation is to determine why the patient is on it and recognizing that reversing the patient is putting them at some sort of risk. Usually within our patient population, patients are on AC for afib, hx of strokes, though other considerations include any sort of hypercoagulable state. Reversing AC should be considered in life threatening bleeding in the ED.
Anticoagulation: Warfarin (brand name Coumadin)
Can be evaluated by INR
Intracranial hemorrhage: immediately give PCC
Reversal:
10 mg IV Vitamin K over 30 minute + PCC or FFP
Of note- PCC/FFP will only work for approximately 8 hours so please give with vitamin K
For supratherapeutic INR with no life threatening bleeding, slowly treat:
INR 3-5:
hold warfarin
INR 5-9:
hold warfarin
Vitamin K (1-2.5 mg PO or IV) if risk for bleeding
INR >9:
Hold warfarin
Vitamin K 2.5-5 mg PO/IV
Anticoagulant: Dabigatran
Can be evaluated by PTT and thrombin time
Reversal:
Idarucizumab 5 g
Dabigatran can be dialyzed out
Anticoagulation: Factor Xa inhibitors (-xaban most commonly apixaban)
Can be evaluated through INR (normal INR goes against a significant drug level though does not exclude it entirely)
Reversal:
4 Factor PCC (KCentra)
Adnexanet Alfa may be considered if available though v expensive
Thrombolytic: tPA
Order INR/PTT/fibrinogen though do not wait for results to reverse
Reversal:
Tranexamic acid:
1 g IV loading dose followed by 1 g infused over the next hour
Cryoprecipitate: start with 10 units
Options: FFPs 2 units and platelet transfusions
Anticoagulation:
Heparin/LMWH:
Measure with PTT
Reverse with protamine
Dosing for protamine is quite intricate and depends on bolus, infusions and timing of both. I would recommend coordinating with pharmacy directly.
Antiplatelet:
Could consider TEG or platelet function assays
Reversal:
Desmopressin (DDAVP) 0.3-0.4 ug/kg infuse over 20-30 minutes
Hopefully this helps as a quick reference, especially for those of us who will be sadly leaving Maimo and our beautiful anticoagulation orderset that makes reversing all of these things downstairs as painless as possible.
https://emcrit.org/ibcc/reverse/
Aldhaeefi M, Badreldin HA, Alsuwayyid F, Alqahtani T, Alshaya O, Al Yami MS, Bin Saleh K, Al Harbi SA, Alshaya AI. Practical Guide for Anticoagulant and Antiplatelet Reversal in Clinical Practice. Pharmacy (Basel). 2023 Feb 11;11(1):34. doi: 10.3390/pharmacy11010034. PMID: 36827672; PMCID: PMC9963371.