Diagnostics and management of direct oral anticoagulants-induced bleeding

To provide evidence-based management of patients on direct oral anticoagulants (DOAC) needing acute procedures, including those facing hemorrhage.

Standard coagulation parameters are insufficient for precise DOAC plasma level measurement; calibrated anti factor X activated assays are reliable, and point-of-care assays may be useful in urgent situations. For intracerebral hemorrhage (ICH) in patients on DOACs, direct reversal strategies seem to be more effective than nonspecific hemostatic agents, but evidence still remains unclear in terms of efficacy and safety compared to nonspecific hemostatic agents. Before invasive procedures like neuraxial anesthesia or cerebral thrombectomy, idarucizumab is recommended for dabigatran-treated patients, despite recent observational data not fully supporting this. No recommendations can be made for FXa inhibitors because of the lack of data.

Clinicians should assess the overall risk of bleeding for an acute procedure or the severity of any ongoing hemorrhage in DOAC-treated patients before initiating any reversal treatment, regardless of current evidence levels.