Managing Bleeding Events Based on Risk Stratification

Minor Bleeding1
(eg., Epistaxis, ecchymosis, menorrhagia)

  • Withdraw NOAC for ≥ 1 day
  • Provide definitive interventions

Major Bleeding1
(eg., upper or lower GI bleeding)

  • Stop anticoagulant, monitor closely
  • Consider activated charcoal if bleeding detected within 2 hours of NOAC ingestion
  • Identify & treat bleeding source
    • If bleeding cannot be controlled or is intracranial and is related to dabigatran, administer 5 grams idarucizumab intravenously
  • Consider extended NOAC withdrawal period
    • Consider low dose parenteral anticoagulant for those at particularly high risk of thrombosis to allow healing
  • Transfuse with RBC for symptomatic anemia
  • Ensure renal function is stable

Major & Life-Threatening Bleeding1-3

  • Immediate withdrawal of anticoagulant and antiplatelet drugs
    • Consider activated charcoal if bleeding detected within 2 hours of NOAC ingestion
    • Consider NOAC offset time and renal function
    • For dabigatran-related bleeding, administer 5 grams idarucizumab intravenously
  • Aggressive clinical monitoring & intervention to identify bleeding source
    • Endoscopy, interventional radiology and/or surgery
  • Transfuse with packed RBC for proven/anticipated anemia
  • Prior to prothrombin complex concentrate (PCC) or rVIIa, consider PT for rivaroxaban or apixaban; or aPTT for dabigatran
    • If results normal, do not institute PCC or rVIIa
    • Contact your institution’s pharmacy for availability and dosing of PCC agents
  • Consider 4-factor PCC replacement therapy

*None of the PCCs is indicated for urgent reversal of anticoagulation. Experience and published use are limited. Consult current references and product labeling for the most current information. Reversal agents are under development.3

1. Schulman S et al. Blood. 2012;119:3016-3023.
2. Weitz JI et al. Circulation. 2012:126;2428-2432.
3. January CT, et al. Circulation 2014 Apr 10. [Epub ahead of print]