The practical management of bleedings during treatment with direct oral anticoagulants: the emergency reversal therapy

  • Luca Masotti | UO Medicina Interna, Ospedale di Cecina (LI), Italy.
  • Giancarlo Landini UO Medicina Interna, Ospedale Santa Maria Nuova, Firenze, Italy.
  • Grazia Panigada UO Medicina Interna, Ospedale di Pescia (PT), Italy.


Bleeding represents the most feared complication of the new oral anticoagulants, direct oral anticoagulants (DOACs), as well as all the antithrombotic therapies. During the acute phase of bleeding in patients taking anticoagulants, restoration of an effective hemostasis represents the cornerstone of practical management. While vitamin K antagonists are effectively and promptly reversed by specific antidotes such as prothrombin complex concentrates (PCCs), fresh frozen plasma or vitamin K, it is still not clear how to manage the urgent reversal of DOACs during life-threatening or major bleedings due to the lack of specific antidotes. However, in vitro and ex vivo studies have suggested some potential strategies to reverse DOACs in clinical practice, other than general support measures that are always recommended. Activated charcoal could be used in subjects with DOAC-related bleedings presenting to the emergency department within two hours of the last oral intake. Non-activated or activated PCCs (FEIBA) and recombinant activated Factor VII (raFVII) seem to be the optimal strategy for urgent reversal of dabigatran, while non-activated PCCs seem to have efficacy in reversing rivaroxaban. Due to its low plasma protein binding, dabigatran could be also dialyzed in urgent cases. Clinically relevant non-major bleedings and minor bleedings should be treated with general and local measures, respectively, and, when necessary, with dose delay or drug withdrawal. In this article, the Authors describe the practical approach to bleedings occurring during DOACs treatment.


Download data is not yet available.

PlumX Metrics

PlumX Metrics provide insights into the ways people interact with individual pieces of research output (articles, conference proceedings, book chapters, and many more) in the online environment. Examples include, when research is mentioned in the news or is tweeted about. Collectively known as PlumX Metrics, these metrics are divided into five categories to help make sense of the huge amounts of data involved and to enable analysis by comparing like with like.

new oral anticoagulants, dabigatran, rivaroxaban, apixaban, warfarin, prothrombin complex concentrates, bleedings, reversal, antidote.
Abstract views: 1052

PDF: 626
Share it
How to Cite
Masotti, L., Landini, G., & Panigada, G. (2013). The practical management of bleedings during treatment with direct oral anticoagulants: the emergency reversal therapy. Italian Journal of Medicine, 7(8s), 48-58.

Most read articles by the same author(s)