-determine if bleeding is:
—low risk (easily compressible and not in a life-threatening space)
—moderate risk (stable GI or retroperitoneal? bleed)
—high risk (ICH, bleeding into pericardium, aortic dissection, spinal epidural hematoma, or ocular/hyphema?, unstable GI or retroperitoneal bleed)
-determine time of last ingestion of the NOAC – if >12-14 hours ago, the anticoagulant effects have worn off and there is little utility in reversal
-have a low threshold for activating MTP
For Xa inhibitors apiXaban (eliquis) or rivaroXaban (xarelto)
First line: 4-factor PCC (Octaplex, Beriplex, Kcentra) at a dose of 50 IU/kg up to 2,000 units.
Note that if you highly suspect a Xa inhibitor intracranial bleed before obtaining a CT head, it is reasonable to give 1,500 units of 4 factor PCC on speculation.
Second Line: Tranexamic acid, 1 gm over 10 minutes and then 1 gm over the next 8 hrs if 4-factor PCC is ineffective.
For Direct Thrombin Inhibitor (DTI) Dabigatran (pradaxa)
First Line: Idarucizumab (Praxbind)
For antiplatelet Ticagrelor (plavix)
-give ddAVP, consider platelet transfusion
High risk procedures for patients on DOACs include lumbar puncture and subclavian central line.
Low risk procedures for patients on DOACs include paracentesis, thoracentesis and non-subclavian central line.
Dose reduction: apixiban/eloquis, enoXaparin/lovenox, and dabigatran/pradaxa require dose reduction for renal excretion and age (rivaroxaban/xarelto does not)