Difference between revisions of "Anticoagulant reversal for life-threatening bleeds"

(External Links)
(11 intermediate revisions by 4 users not shown)
Line 28: Line 28:
 
*Use protamine for partial neutralization (~60%)  
 
*Use protamine for partial neutralization (~60%)  
 
*[[Protamine]] IV:  
 
*[[Protamine]] IV:  
**< 8 hours since last dose: [[Protamine]] 50 mg
+
**< 8 hours since last dose: [[Protamine]] 50mg
**8-12 hours since last dose: [[Protamine]] 25 mg
+
**8-12 hours since last dose: [[Protamine]] 25mg
 
**>12 hours since last dose: Unlikely useful unless CrCl < 30 mL/min (or 25mg fixed dose)
 
**>12 hours since last dose: Unlikely useful unless CrCl < 30 mL/min (or 25mg fixed dose)
 
*Dose of protamine for each 100 units dalteparin or 1mg of enoxaparin administered  
 
*Dose of protamine for each 100 units dalteparin or 1mg of enoxaparin administered  
Line 37: Line 37:
 
| [[Enoxaparin]] (Lovenox®)||3-5 hrs (longer in renal impairment)||~ 20%||As above
 
| [[Enoxaparin]] (Lovenox®)||3-5 hrs (longer in renal impairment)||~ 20%||As above
 
|-
 
|-
| [[Hepari]]n||30-90 min (dose dependent)||Partial||
+
| [[Unfractionated heparin]]||30-90 min (dose dependent)||Partial||
 
*Turn off infusion  
 
*Turn off infusion  
*[[Protamine]] 50 mg IV
+
*[[Protamine]] 50mg IV
 
|}
 
|}
  
===Warfarin (Coumadin®)===
+
===[[Warfarin]](Coumadin®)===
 
{| {{table}}
 
{| {{table}}
 
| align="center" style="background:#f0f0f0;"|'''INR'''
 
| align="center" style="background:#f0f0f0;"|'''INR'''
Line 56: Line 56:
 
| > 10||No bleeding||
 
| > 10||No bleeding||
 
*Hold warfarin until INR in therapeutic range  
 
*Hold warfarin until INR in therapeutic range  
*Consider [[vitamin K]] 2.5 mg oral or 1-2 mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)  
+
*Consider [[vitamin K]] 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)  
 
|-
 
|-
 
| ||Rapid reversal required||
 
| ||Rapid reversal required||
 
*Hold warfarin  
 
*Hold warfarin  
*Consider [[vitamin K]] 2.5 mg oral or 1-2 mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)  
+
*Consider [[vitamin K]] 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)  
 
|-
 
|-
 
| 4.5-10||No bleeding||
 
| 4.5-10||No bleeding||
Line 68: Line 68:
 
| ||Rapid reversal required||
 
| ||Rapid reversal required||
 
*Hold warfarin  
 
*Hold warfarin  
*Consider [[vitamin K]] 2.5 mg oral or 1 mg IV infusion (IV administration of vitamin K has faster onset of action)  
+
*Consider [[vitamin K]] 2.5mg oral or 1mg IV infusion (IV administration of vitamin K has faster onset of action)  
 
|-
 
|-
 
| < 4.5||No bleeding||
 
| < 4.5||No bleeding||
Line 75: Line 75:
 
| ||Rapid reversal required||
 
| ||Rapid reversal required||
 
*Hold warfarin  
 
*Hold warfarin  
*Consider [[vitamin K]] 2.5 mg oral
+
*Consider [[vitamin K]] 2.5mg oral
 
|}
 
|}
  
 
==See Also==
 
==See Also==
 
*[[Coagulopathy (main)]]
 
*[[Coagulopathy (main)]]
 +
*[[Anti-platelet agent reversal]]
  
 
==External Links==
 
==External Links==
 +
[https://journalfeed.org/article-a-day/2019/anticoagulant-reversal-strategies-and-coi JournalFeed Summary with Flowsheet] of ”Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.” by Baugh et. al. from Annals 2019<ref>[https://www.ncbi.nlm.nih.gov/pubmed/31732375?dopt=AbstractPlus Baugh et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med. 2019 Nov 13. pii: S0196-0644(19)31181-3]</ref>
  
 
==References==
 
==References==

Revision as of 11:27, 9 December 2019

Factor Xa Inhibitor Reversal

Anticoagulant Half-life Removed by HD Strategies to reverse or minimize anticoagulant effects
Apixaban[1] (Eliquis®) 8-15 hrs (longer in renal impairment) No
  • If ingested within 2 hours, administer activated charcoal
  • 4-factor PCC (Kcentra™)^
    • 25units/kg—max 2500 units for treatment of documented intracranial hemorrhage
    • 50 units/kg—max 5000 units for all other life-threatening bleeds
Edoxaban[2] (Savaysa®) 10-14 hrs (longer in renal impairment) ~ 25% As above
Rivaroxaban[3] (Xarelto®) 9-13 hrs (longer in renal impairment) No As above
Fondaparinux (Arixtra®) 17-21 hrs (significantly longer in renal impairment) No 4-factor PCC (Kcentra™)^ 50 units/kg—max 5000 units

^Off-label

Andexanet alfa

FDA approved in May 2018, limited availability June 2018

Low Dose

400 mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by 4 mg/minute for up to 120 minutes

High Dose

800 mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by 8 mg/minute for up to 120 minutes

Direct Thrombin Inhibitor

Anticoagulants Half-life Removed by HD Strategies to reverse or minimize anticoagulant effects
Argatroban 40-50 min ~ 20% Turn off infusion
Bivalirudin (Angiomax®) 25 min (up to 1 hr in severe renal impairment) ~ 25% As above
Dabigatran (Pradaxa®) 14-17 hrs (up to 34 hrs in severe renal impairment) ~ 65%
  • If ingested within 2 hours, administer activated charcoal
  • Idarucizumab (Praxbind®) 5g IV
  • For end stage renal disease patient with pre-existing vascular access, consult nephrology to consider dialysis.

Heparins

Anticoagulants Half-life Removed by HD Strategies to reverse or minimize anticoagulant effects
Dalteparin (Fragmin®) 3-5 hrs (longer in renal impairment) ~ 20%
  • Use protamine for partial neutralization (~60%)
  • Protamine IV:
    • < 8 hours since last dose: Protamine 50mg
    • 8-12 hours since last dose: Protamine 25mg
    • >12 hours since last dose: Unlikely useful unless CrCl < 30 mL/min (or 25mg fixed dose)
  • Dose of protamine for each 100 units dalteparin or 1mg of enoxaparin administered
  • Obtain baseline anti-Xa activity level
  • Monitor anti-Xa activity level to confirm reversal
Enoxaparin (Lovenox®) 3-5 hrs (longer in renal impairment) ~ 20% As above
Unfractionated heparin 30-90 min (dose dependent) Partial

Warfarin(Coumadin®)

INR Clinical scenario Management
Any Serious or life-threatening bleed
  • Hold warfarin
  • Give vitamin K 10mg IV infusion over 30 minutes
  • Give FFP/plasma or
  • Consider 4-factor PCC (Kcentra™)—preferred for life-threatening bleeds
> 10 No bleeding
  • Hold warfarin until INR in therapeutic range
  • Consider vitamin K 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)
Rapid reversal required
  • Hold warfarin
  • Consider vitamin K 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)
4.5-10 No bleeding
  • Hold warfarin until INR in therapeutic range
  • Consider vitamin K 2.5mg oral
Rapid reversal required
  • Hold warfarin
  • Consider vitamin K 2.5mg oral or 1mg IV infusion (IV administration of vitamin K has faster onset of action)
< 4.5 No bleeding
  • Hold warfarin until INR in therapeutic range
Rapid reversal required

See Also

External Links

JournalFeed Summary with Flowsheet of ”Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.” by Baugh et. al. from Annals 2019[4]

References

  1. Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.
  2. Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.
  3. Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.
  4. Baugh et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med. 2019 Nov 13. pii: S0196-0644(19)31181-3
  • Harbor-UCLA Medical Center Guidelines Approved by Anticoagulation Subcommittee on 3/17/2016 Approved by Pharmacy and Therapeutic Committee on 3/17/2016
  • Hatfield L and Chen SL. University of North Carolina Healthcare Anticoagulation Reversal Guidelines. June 2014.
  • Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.
  • Pradaxa prescribing information. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; January 2012.
  • Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.
  • Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.