DOACs THERAPY &

REVERSAL
STRATEGIES FOR
DOACs RELATED
BLEEDING

Speaker
Rimsha Ismail (Rph)
 LEARNING OBJECTIVES

• DOAC’S Overview
• Discuss the incidence, risk factors and severity of bleeding
complications associated with the use of direct‐acting anticoagulant
(DOAC) therapy.
• Discuss the normal coagulation pathway and (DOAC) mechanism
on it.
• Given patient characteristics, develop a systematic patient
assessment approach to identify the optimal anticoagulant reversal
strategy.
• Summarize recent clinical evidence regarding the safety and
efficacy of DOAC reversal.
OVER VIEW OF DOACs
Coagulation Cascade
DOSING ADJUSTMENTS
DOSING ADJUSTMENTS
WHEN TO USE
 PATIENT ASSESSMENT
Accuracy is key
 DOAC type
 Dose
 Last dose administered
Major/life‐threatening bleed
 Other medications
 Antiplatelets
 Drug‐drug interaction
Lab monitoring
 APTT
 INR test
Removal Options
Prothrombin Complex
Concentrate

Idarucizumab

Andexanet alfa

Fresh Frozen Plasma

Vitamin K
Specific Reversal Agents
VITAMIN ‘’K’’ AS AN ANTI-DOTE

Indication Management Vitamin K

considerations administration

Supratherapeutic INR and

no evidence of bleeding

INR 4.5 to 10 Discontinue warfarin, monitor oral vitamin K 1 to 2.5 mg is

INR frequently recommended

INR >10 Discontinue warfarin, monitor oral vitamin K 2.5 to 5 mg is

INR frequently usually recommended;
recheck INR after 12 to 24
hours; may administer a
second dose if necessary.
mechanical prosthetic heart
Bleeding
Minor bleeding Discontinue warfarin, If administered, oral vitamin
monitor INR frequently K 2.5 to 5 mg is
recommended; if INR
remains elevated after 24
hours, may administer
another dose.

Major bleeding into a Discontinue warfarin and Administer IV vitamin K 10

critical site and/or life- urgently administer a 4- mg over 10 to 20 minutes
threatening bleeding factor PCCh in combination (maximum infusion rate: 1
(including intracranial with IV vitamin K; monitor mg/minute) as soon as
hemorrhage) INR frequently and assess possible in combination with
for hemostasis. a 4-factor PCC; if INR
remains elevated after 12 to
24 hours, may administer
Invasive procedure or
surgery

Elective Administer oral vitamin
K 1 to 2.5 mg once if
needed the day before
the procedure/surgery

Urgent Administer IV vitamin K 1
to 10 mg over 10 to 20
minutes (maximum
infusion rate: 1
 HEPARIN INDUCED
THROMBOCYTOPENIA(HIT)
 HEPARIN INDUCED
THROMBOCYTOPENIA(HIT)

Apixaban
Oral: 10 mg twice daily for 7 days or until platelet count recovery,
whichever is longer, followed by 5 mg twice daily.
 
Rivaroxaban
Oral: 15 mg twice daily with food for 21 days or until platelet count recovery,
whichever is longer, followed by 20 mg once daily with food.
THANK YOU