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

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===Factor Xa Inhibitors===
 
{| {{table}}
 
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Class'''
 
 
| align="center" style="background:#f0f0f0;"|'''Anticoagulants'''
 
| align="center" style="background:#f0f0f0;"|'''Anticoagulants'''
 
| align="center" style="background:#f0f0f0;"|'''Half-life'''
 
| align="center" style="background:#f0f0f0;"|'''Half-life'''
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| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
 
| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
 
|-
 
|-
| Factor Xa Inhibitor||Apixaban (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
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| Apixaban (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
 
|-
 
|-
| 1||Edoxaban (Savaysa®)||10-14 hrs (longer in renal impairment)||~ 25%||As above
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| Edoxaban (Savaysa®)||10-14 hrs (longer in renal impairment)||~ 25%||As above
 
|-
 
|-
| 1||Rivaroxaban (Xarelto®)||9-13 hrs (longer in renal impairment)||No||As above
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| Rivaroxaban (Xarelto®)||9-13 hrs (longer in renal impairment)||No||As above
 
|-
 
|-
| 1||Fondaparinux (Arixtra®)||17-21 hrs (significantly longer in renal impairment)||No||4-factor PCC (Kcentra™)* 50 units/kg—max 5000 units
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| Fondaparinux (Arixtra®)||17-21 hrs (significantly longer in renal impairment)||No||4-factor PCC (Kcentra™)* 50 units/kg—max 5000 units
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|}
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===Direct Thrombin Inhibitor===
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{| {{table}}
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| align="center" style="background:#f0f0f0;"|'''Anticoagulants'''
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| align="center" style="background:#f0f0f0;"|'''Half-life'''
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| align="center" style="background:#f0f0f0;"|'''Removed by HD'''
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| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
 
|-
 
|-
| Direct Thrombin Inhibitor||Argatroban||40-50 min ||~ 20%||Turn off infusion
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| Argatroban||40-50 min ||~ 20%||Turn off infusion
 
|-
 
|-
| 1||Bivalirudin (Angiomax®)||25 min (up to 1 hr in severe renal impairment)||~ 25%||As above
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| Bivalirudin (Angiomax®)||25 min (up to 1 hr in severe renal impairment)||~ 25%||As above
 
|-
 
|-
| 1||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.
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| 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.
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|}
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===Heparins===
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{| {{table}}
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| align="center" style="background:#f0f0f0;"|'''Anticoagulants'''
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| align="center" style="background:#f0f0f0;"|'''Half-life'''
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| align="center" style="background:#f0f0f0;"|'''Removed by HD'''
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| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
 
|-
 
|-
| Low Molecular Weight Heparin||Dalteparin (Fragmin®)||3-5 hrs (longer in renal impairment)||~ 20%||*Use protamine for partial neutralization (~60%) *Protamine IV: **< 8 hours since last LMWH dose: Protamine 50 mg **8-12 hours since last LMWH dose: Protamine 25 mg **>12 hours since last LMWH 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  
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| Dalteparin (Fragmin®)||3-5 hrs (longer in renal impairment)||~ 20%||*Use protamine for partial neutralization (~60%) *Protamine IV: **< 8 hours since last LMWH dose: Protamine 50 mg **8-12 hours since last LMWH dose: Protamine 25 mg **>12 hours since last LMWH 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  
 
|-
 
|-
| 1||Enoxaparin (Lovenox®)||||||As above
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| Enoxaparin (Lovenox®)||||||As above
 
|-
 
|-
| UFH||Heparin||30-90 min (dose dependent)||Partial||*Turn off infusion *Protamine 50 mg IV
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| Heparin||30-90 min (dose dependent)||Partial||*Turn off infusion *Protamine 50 mg IV
 
|}
 
|}
  

Revision as of 07:06, 25 March 2016

Factor Xa Inhibitors

Anticoagulants Half-life Removed by HD Strategies to reverse or minimize anticoagulant effects
Apixaban (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 (Savaysa®) 10-14 hrs (longer in renal impairment) ~ 25% As above
Rivaroxaban (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

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 LMWH dose: Protamine 50 mg **8-12 hours since last LMWH dose: Protamine 25 mg **>12 hours since last LMWH 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®) As above
Heparin 30-90 min (dose dependent) Partial *Turn off infusion *Protamine 50 mg IV

See Also

External Links

References