NOACs: Management of bleeding under NOAC therapy
Evaluation
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NOAC dosage and last intake time.
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Co-medications: antiplatelets, NSAIDs, alcohol, and OTC drugs.
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Blood tests for creatinine, liver function, and CBC.
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Rapid coagulation assessment and plasma drug level (if available).
Bleeding definition
Mild bleeding (clinically relevant nonmajor bleeding)
Non-life-threatening major bleeding
Life-threatening- or bleeding into a critical site
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Requiring medical intervention by a health care professional
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Leading to hospitalization or increased level of care
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Prompting a face-to-face evaluation
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Clinically overt bleeding in excess of expected and
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associated with a fall of 2 g of hemoglobin per dl and/or
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leading to transfusion of > 2 U PRC or whole blood
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Fetal bleeding
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Symptomatic retroperitoneal, intracranial, intraocular or intraspinal bleeding
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Any clinically overt sign of hemorrhage associated with a fall in hemoglobin of 3 to ≤5 g/dl or hematocrit of 9 to ≤15%
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Requiring medical attention:(and does not meet criteria for major or minor bleeding)
-Bleeding requiring intervention
-Bleeding leading to prolonged hospitalisation
-Bleeding prompting evaluation
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Clinically overt hemorrhage with > 5 g/dL decrease in Hb (hematocrit of >15%)
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Intracranial bleeding
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Fetal bleeding (death within 7 days)
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Bleed without blood transfusion or hemodynamic compromise
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Bleeding requiring transfusion of whole blood or PRBC without hemodynamic compromise.
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Any of the following
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Fatal
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Intracranial
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Bleeding that caused
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hemodynamic compromise requiring intervention (eg, SBP<90 mmHg that required blood or fluid replacement, vasopressor/inotropic support, or surgical intervention)
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Management
Delay or discontinue the next dose
Reconsider concomitant medication
Reconsider the choice of NOAC & dosing
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Supportive
- Mechanical compression
- GI bleeding: Endoscopic hemostasis
- Surgical hemostasis
- Fluid replacement; RBC/ platelet substitution
- Consider adjuvant tranexamic acid
- Treatment of factors/ comorbidities contributing to bleeding -
For dabigatran:
- Consider idarucizumab
or hemodialysis (if idarucizumab is not available)
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Dabigatran: idarucizumab 5 g i.v.
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Idarucizumab 5 g i.v. in 2 consecutive infusions of 2.5g i.v. over 5-10 minutes each (or as a bolus)
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Factor Xa inhibitor: Andexanet alpha (see below)
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Otherwise, consider:
PCC 50 U/kg; + 25 U/kg if indicated
aPCC 50 U/kg: max 200 U/kg/day
Andexanet alpha
Low dose: Bolus 400 mg (at 30 mg/min) then infusion 4 mg/min over two hours (480 mg).
Post-bleeding management
- Discuss how bleeding affects the patient's evaluation of the risks and benefits of anticoagulation.
- Assess the risk of recurrent bleeding.
- Re-evaluate modifiable factors that contribute to bleeding risk.
- Review the correct selection and dosing of NOACs (Novel Oral Anticoagulants).
- Re-initiate anticoagulation in the absence of absolute contraindications, using a shared decision-making approach.
References
Jan Steffel, Ronan Collins, Matthias Antz, Pieter Cornu, Lien Desteghe, Karl Georg Haeusler, Jonas Oldgren, Holger Reinecke, Vanessa Roldan-Schilling, Nigel Rowell, Peter Sinnaeve, Thomas Vanassche, Tatjana Potpara, A John Camm, Hein Heidbüchel, External reviewers , 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation, EP Europace, Volume 23, Issue 10, October 2021, Pages 1612–1676, https://doi.org/10.1093/europace/euab065