Anticoagulant reversal for life-threatening bleeds: Difference between revisions
Neil.m.young (talk | contribs) (Text replacement - "0 mg" to "0mg") |
Neil.m.young (talk | contribs) (Text replacement - "5 mg" to "5mg") |
||
| Line 29: | Line 29: | ||
*[[Protamine]] IV: | *[[Protamine]] IV: | ||
**< 8 hours since last dose: [[Protamine]] 50mg | **< 8 hours since last dose: [[Protamine]] 50mg | ||
**8-12 hours since last dose: [[Protamine]] | **8-12 hours since last dose: [[Protamine]] 25mg | ||
**>12 hours since last dose: Unlikely useful unless CrCl < 30 mL/min (or 25mg fixed dose) | **>12 hours since last dose: Unlikely useful unless CrCl < 30 mL/min (or 25mg fixed dose) | ||
*Dose of protamine for each 100 units dalteparin or 1mg of enoxaparin administered | *Dose of protamine for each 100 units dalteparin or 1mg of enoxaparin administered | ||
| Line 56: | Line 56: | ||
| > 10||No bleeding|| | | > 10||No bleeding|| | ||
*Hold warfarin until INR in therapeutic range | *Hold warfarin until INR in therapeutic range | ||
*Consider [[vitamin K]] 2. | *Consider [[vitamin K]] 2.5mg oral or 1-2 mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action) | ||
|- | |- | ||
| ||Rapid reversal required|| | | ||Rapid reversal required|| | ||
*Hold warfarin | *Hold warfarin | ||
*Consider [[vitamin K]] 2. | *Consider [[vitamin K]] 2.5mg oral or 1-2 mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action) | ||
|- | |- | ||
| 4.5-10||No bleeding|| | | 4.5-10||No bleeding|| | ||
| Line 68: | Line 68: | ||
| ||Rapid reversal required|| | | ||Rapid reversal required|| | ||
*Hold warfarin | *Hold warfarin | ||
*Consider [[vitamin K]] 2. | *Consider [[vitamin K]] 2.5mg oral or 1 mg IV infusion (IV administration of vitamin K has faster onset of action) | ||
|- | |- | ||
| < 4.5||No bleeding|| | | < 4.5||No bleeding|| | ||
| Line 75: | Line 75: | ||
| ||Rapid reversal required|| | | ||Rapid reversal required|| | ||
*Hold warfarin | *Hold warfarin | ||
*Consider [[vitamin K]] 2. | *Consider [[vitamin K]] 2.5mg oral | ||
|} | |} | ||
Revision as of 08:54, 19 July 2016
Factor Xa Inhibitor Reversal
| Anticoagulant | Half-life | Removed by HD | Strategies to reverse or minimize anticoagulant effects |
| Apixaban[1] (Eliquis®) | 8-15 hrs (longer in renal impairment) | No |
|
| Edoxaban[2] (Savaysa®) | 10-14 hrs (longer in renal impairment) | ~ 25% | As above |
| Rivaroxaban[3] (Xarelto®) | 9-13 hrs (longer in renal impairment) | No | As above |
| Fondaparinux (Arixtra®) | 17-21 hrs (significantly longer in renal impairment) | No | 4-factor PCC (Kcentra™)^ 50 units/kg—max 5000 units |
^Off-label
Andexanet alfa
FDA approved in May 2018, limited availability June 2018
- Cost is $20,000 to $55,000 per dose
- Trial that led to FDA approval does not have the most sound evidence behind it [4]:
- Prospective single center single group study of 352 patients receiving a Factor Xa Inhibitor (apixaban, rivaroxaban, edoxaban, enoxaparin) with life threatening bleed (those with expected survival <1 month were excluded).
- Anti-Factor Xa activity was decreased in all groups. 82% were judged to have excellent hemostatic control. 14% mortality rate at 30 days.
- No comparison group available. It is unlikely that following anti-Factor Xa activity as a lab value is clinically important. High mortality rate even after excluding sick patients.
Low Dose
400 mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by 4 mg/minute for up to 120 minutes
High Dose
800 mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by 8 mg/minute for up to 120 minutes
Direct Thrombin Inhibitor
| Anticoagulants | Half-life | Removed by HD | Strategies to reverse or minimize anticoagulant effects |
| Argatroban | 40-50 min | ~ 20% | Turn off infusion |
| Bivalirudin (Angiomax®) | 25 min (up to 1 hr in severe renal impairment) | ~ 25% | As above |
| Dabigatran (Pradaxa®) | 14-17 hrs (up to 34 hrs in severe renal impairment) | ~ 65% |
|
Heparins
| Anticoagulants | Half-life | Removed by HD | Strategies to reverse or minimize anticoagulant effects |
| Dalteparin (Fragmin®) | 3-5 hrs (longer in renal impairment) | ~ 20% |
|
| Enoxaparin (Lovenox®) | 3-5 hrs (longer in renal impairment) | ~ 20% | As above |
| Heparin | 30-90 min (dose dependent) | Partial |
|
Warfarin (Coumadin®)
| INR | Clinical scenario | Management |
| Any | Serious or life-threatening bleed | |
| > 10 | No bleeding |
|
| Rapid reversal required |
| |
| 4.5-10 | No bleeding |
|
| Rapid reversal required |
| |
| < 4.5 | No bleeding |
|
| Rapid reversal required |
|
See Also
External Links
References
- ↑ Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.
- ↑ Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.
- ↑ Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.
- ↑ Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019
- Harbor-UCLA Medical Center Guidelines Approved by Anticoagulation Subcommittee on 3/17/2016 Approved by Pharmacy and Therapeutic Committee on 3/17/2016
- Hatfield L and Chen SL. University of North Carolina Healthcare Anticoagulation Reversal Guidelines. June 2014.
- Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.
- Pradaxa prescribing information. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; January 2012.
- Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.
- Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.