Bleeding Risk Associated with Novel Oral Anticoagulants in Critically Ill Patients: A Scoping Review

Area of Science:

• Pharmacology
• Critical Care Medicine
• Hematology

Background:

• Novel oral anticoagulants (NOACs) are crucial for thromboembolic disease prevention and treatment.
• Critically ill patients are underrepresented in pivotal NOAC clinical trials, limiting evidence for their specific use.
• Critical illness involves complex pathophysiology, organ dysfunction, and inflammation that can alter anticoagulant efficacy and bleeding risk.

Purpose of the Study:

• To systematically map and synthesize evidence on bleeding risk associated with NOACs in critically ill patients.
• To identify ICU-specific risk factors, underlying pathophysiological mechanisms, and management strategies for NOAC-related bleeding.
• To assess the adequacy and applicability of current evidence for managing NOACs in intensive care settings.

Main Methods:

• A scoping review methodology was employed.
• Synthesized findings from reviews, observational studies, clinical trials, and guidelines.
• Focused on critically ill populations including those with organ dysfunction, sepsis, malignancy, and post-operative status.

Main Results:

• Bleeding risk is influenced by renal/hepatic dysfunction, advanced age, malignancy, polypharmacy, and antiplatelet use.
• Gastrointestinal and intracranial hemorrhages are the most significant bleeding complications.
• Bleeding risk in critically ill patients on NOACs is highly variable and dynamic, influenced by numerous patient and illness factors.

Conclusions:

• The current evidence base is inadequate to fully address the heterogeneity and dynamic nature of NOAC-associated bleeding risk in critically ill patients.
• Existing data does not adequately capture the diverse clinical contexts within intensive care units.
• Prospective, ICU-specific studies are needed to better define bleeding risks and inform anticoagulation strategies and risk stratification for this population.