Specific reversal agents exist for vitamin K antagonists (vitamin K and prothrombin complex concentrate), heparins (protamine sulphate) and dabigatran (Idarucizumab) but there is currently no specific reversal agent for fondaparinux or for the oral factor Xa inhibitorsĪ decision to reverse anticoagulation must weigh the benefits of anticoagulation reversal in terms of stopping bleeding or reduction of bleeding risk against the risk of development or extension of thrombosis while anticoagulation is reversed. INR and APTT can be used to assess anticoagulant activity of vitamin K antagonists and unfractionated heparin respectively, but therapeutic ranges for these drugs cannot be used to interpret clotting tests in patients on other anticoagulants In patients bleeding while on anticoagulants, supportive treatment including blood components and local measures should be employed alongside the steps taken to reverse the anticoagulant effect The type of anticoagulant, dose, timing of last dose and indication are significant points to establish when making decisions about anticoagulation reversalįor elective procedures and surgery, the need for anticoagulation reversal should be avoided by determining whether cessation of anticoagulant is required, and by following local bridging protocols Finally, consideration of whether and when to reintroduce an anticoagulant drug following reversal is important not only to balance bleeding and thrombotic risks for individual patients but also for timely management of discharge. It is also necessary to reduce the need for reversal through correct prescribing and by employing appropriate periprocedural bridging strategies for elective and semi-elective procedures. An understanding of reversal strategies alone is insufficient to competently care for patients who may require anticoagulation reversal.
Recognising effects upon, and limitations of, laboratory measures of coagulation also plays an important role.
While supportive and general measures apply for patients on all agents, recent diversification in the number of licensed agents makes an understanding of drug-specific reversal strategies essential. Widespread use of anticoagulant drugs for treatment and prevention of thromboembolic events means it is common to encounter patients requiring reversal of anticoagulation for management of bleeding or invasive procedures.
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