Major haemorrhage and emergency invasive procedures for direct or novel oral anticoagulants

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There is no specific antidote available yet for apixaban, edoxaban or rivaroxaban. The key principles in managing these situations are:

  • Assess coagulation screen and renal function, bearing in mind the limited prolongation of prothrombin time (PT) and activated partial thromboplastin time (APTT) induced by therapeutic doses of apixaban, dabigatran, edoxaban and rivaroxaban.
  • Ascertain time of the most recent dose of anticoagulant, and administer no further doses. If very recent ingestion (<2h) consider administration of oral activated charcoal to inhibit absorption.
  • If significant dabigatran effect, as assessed by coagulation screen (eg APPT >50s), and idarucizumab is unavailable or contraindicated, consider feasibility of urgent haemodialysis to remove anticoagulant. Discuss with on-call Renal Consultant. See over page for further guidance.
  • Consider possibility of delaying major surgery until the anticoagulant effect has sufficiently dissipated.
  • If major surgery has to proceed in the face of significant anticoagulant effect:
    • ensure haemostatic platelet count and fibrinogen level and satisfactory pre-operative Hb
    • treat any additional causes of coagulopathy
    • consider general haemostatic measures (eg intravenous tranexamic acid)
    • if despite the above measures there is significant peri- or post-operative bleeding discuss with Haematologist and consider administration of prothrombin complex concentrate (beriplex 30iu/kg).
  • In the presence of major bleeding:
    • follow general major haemorrhage protocol – see separate algorithms for dabigatran-treated and apixaban/edoxaban/rivaroxaban-treated patients (Appendices 1 and 2).
  • Once haemostasis is secured and/or the invasive procedure completed introduce thromboprophylaxis with low molecular weight heparin (LMWH) when appropriate. If dabigatran or apixaban/edoxaban/rivaroxaban is to be re-introduced this should be deferred until 24 hours after the last dose of LMWH.
Appendix 1: Patient receiving dabigatran therapy: haemorrhage protocol




Appendix 2: Patient receiving apixaban, edoxaban or rivaroxaban therapy: haemorrhage protocol

Abbreviation Meaning
eGFR Estimated glomerular filtration rate
IV Intravenous
BP Blood pressure
Hb Haemoglobin
Plt Platelet count
CNS Central nervous system
Editorial Information

Last reviewed: 31 March 2018

Next review: 31 March 2020

Author(s): Consultant Haematologist

Approved By:

Reviewer Name(s): Joanne Craig

Document Id: TAM121