Anticoagulant reversal for life-threatening bleeds

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Class Anticoagulants Half-life Removed by HD 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
1 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
1 Fondaparinux (Arixtra®) 17-21 hrs (significantly longer in renal impairment) No 4-factor PCC (Kcentra™)* 50 units/kg—max 5000 units
Direct Thrombin Inhibitor Argatroban 40-50 min ~ 20% Turn off infusion
1 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.
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
1 Enoxaparin (Lovenox®) As above
UFH Heparin 30-90 min (dose dependent) Partial *Turn off infusion *Protamine 50 mg IV

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