[Management of emergencies in direct oral anticoagulant-treated patients: practice pearls]

Direct oral anticoagulants have become first-line agents in anticoagulation therapy in recent years; however, their reversal may be challenging in emergency situations, such as massive bleeding or urgent surgery. Conventional coagulation tests are not suitable for accurately assessing anticoagulant activity, making specific monitoring methods (e.g., anti-FXa, viscoelastic tests) essential. Among antidotes, idarucizumab is effective for rapidly reversing the effects of dabigatran, while andexanet alfa neutralizes apixaban and rivaroxaban, though its availability and thrombosis risk limit its use. Alternative strategies include prothrombin complex concentrate or extracorporeal techniques. Determining anticoagulant plasma concentrations before urgent interventions aids clinical decision-making, but in critical cases, hemostatic therapy should commence without awaiting lab results. Following bleeding management, timely reinitiation of anticoagulation is crucial to mitigate thrombotic risk. Orv Hetil. 2025; 166(27): 1043–1052.