DOAC: BLEEDING

• Patient on DOAC e.g. dabigatran/rivaroxaban with bleeding 

• Stop dabigatran/rivaroxaban
• Urgent FBC, U&E, PT, APTT, TT
• Contact on-call haematologist

• Standard anti-coagulation tests can only be used to detect absence of activity

PT, APTT, TT normal

• Bleeding unlikely to be due to dabigatran/rivaroxaban
• either no anticoagulant activity or activity equivalent to prophylactic LMWH
• Consider other possibilities

PT, APTT, TT abnormal

• Anticoagulant effect may be present

Mild bleeding

• Mechanical compression
• Tranexamic acid (25 mg/kg oral; 15 mg/kg IV)
• Delay next dose

Major bleeding

• Maintain BP, urine output
• If drug ingestion <2 hr, use activated charcoal
• Mechanical/surgical intervention to control bleeding
• Tranexamic acid (25 mg/kg oral; 15 mg/kg IV)
• Octaplex (40 u/kg) or Beriplex (50 u/kg) or FEIba (50–100 u/kg)
• discuss with on-call haematologist
• Red cell transfusion
• Platelet transfusion to keep platelets >50
• if CNS bleed, keep platelets >100 

Life-threatening bleeding

• For dabigatran only, consider haemodialysis
• Maintain BP, urine output
• If drug ingestion <2 hr, use activated charcoal
• Mechanical/surgical intervention to control bleeding
• Tranexamic acid
• Octaplex (40 u/kg) or Beriplex (50 u/kg) or FEIba (50–100 u/kg)
• discuss with on-call haematologist
• Red cell transfusion
• Platelet transfusion
• if CNS bleed, keep platelets >50 or >100

Dabigatran

• Site of action: Direct Thrombin inhibitor
• Impact on standard coagulation tests: APPTT, TT
• Half-life (normal renal function): 12-14 hr
• Renal excretion: 80%
• Current indication: VTE prevention, AF
• Reversal in case of bleeding: Discuss with consultant haematologist

Rivaroxaban

• Site of action: Xa inhibitor
• Impact on standard coagulation tests: PT, anti Xa
• Half-life (normal renal function): 9–13 hr
• Renal excretion: 66%
• Current indication: VTE prevention and treatment, AF
• Reversal in case of bleeding: PCC, FEIba, rVIIa

Abixaban

• Site of action: Xa inhibitor
• Impact on standard coagulation tests: PT, anti Xa
• Half-life (normal renal function): 8–15 hr
• Renal excretion: 25%
• Current indication: VTE prevention
• Reversal in case of bleeding: Discuss with consultant haematologist