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Highly Accessed Review

Clinical review: Clinical management of new oral anticoagulants: a structured review with emphasis on the reversal of bleeding complications

Alejandro Lazo-Langner12*, Eddy S Lang3 and James Douketis4

Author Affiliations

1 Department of Medicine, University of Western Ontario, 800 Commissioners Rd. East, Room A2-401, London, ON, Canada, N6A 5W9

2 Department of Epidemiology and Biostatistics, University of Western Ontario, 800 Commissioners Rd. East, Room A2-401, London, ON, Canada, N6A 5W9

3 Division of Emergency Medicine, Department of Family Medicine University of Calgary, Unit 1633, 1632 14 Avenue NW, Calgary, AB, Canada, T2N 1M7

4 Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, 50 Charlton Avenue East, Hamilton, ON, Canada, L8N 4A6

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Critical Care 2013, 17:230  doi:10.1186/cc12592

Published: 17 June 2013

Abstract

New oral anticoagulants, including dabigatran, rivaroxaban, and apixaban, have been recently approved for primary and secondary prophylaxis of thromboembolic conditions. However, there is no clear strategy for managing and reversing their anticoagulant effects. We aimed to summarize the available evidence for clinical management and reversal of bleeding associated with new oral anticoagulants. Using a systematic review approach, we aimed to identify studies describing reversal strategies for dabigatran, rivaroxaban, and apixaban. The search was conducted using Medline, EMBASE, HealthSTAR, and grey literature. We included laboratory and human studies. We included 23 studies reported in 37 out of 106 potentially relevant references. Four studies were conducted in humans and the rest were in vitro and in vivo studies. The majority of the studies evaluated the use of prothrombinase complex concentrate (PCC), either activated or inactivated, and recombinant activated factor VII (rFVIIa). Other interventions were also identified. Laboratory studies suggest that hemostatic parameters and bleeding might be partially or completely corrected by PCC for rivaroxaban better than dabigatran. Studies in humans suggest that PCC might reverse the effects of rivaroxaban better than dabigatran assessed by hemostatic tests. We were not able to locate studies evaluating the clinical efficacy of these agents. The best available evidence suggests that PCC (activated or inactivated) might be the best option for reversing new anticoagulants. Evidence for rFVIIa is less compelling. There might be differences in the efficacy of reversing agents for different anticoagulants. Studies assessing the clinical efficacy of these reversal agents are urgently needed.