Expert Opinion on Implementing Oral Anticoagulation Reversal Protocols in US Hospitals

Oral anticoagulants (OACs), including vitamin K antagonists and direct-acting OACs, are commonly used for the prevention and treatment of thrombosis. OAC-treated patients may require urgent anticoagulation reversal in circumstances of life-threatening bleeding or emergent surgery. Despite the availability of Food and Drug Administration-approved OAC reversal agents, published treatment guidelines, and institutional protocols, use of OAC reversal products and dosing vary considerably and off-label use is common. We review key factors influencing current clinical practice and examine barriers to the successful implementation of anticoagulation protocols, including discrepancies in the definition of major bleeding, dosing considerations, variability in laboratory testing practices, inconsistent study endpoints, formulary considerations, and the use of OAC reversal agents in special populations. We provide our expert opinion on best practices for oral anticoagulant reversal and an anticoagulation reversal protocol that could be implemented by healthcare institutions to standardize and optimize clinical practice.