Ver el código de «Anticoagulant reversal for life-threatening bleeds»

{{Factor Xa Inhibitor Reversal}}

===Direct Thrombin Inhibitor===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Anticoagulants'''
| align="center" style="background:#f0f0f0;"|'''Half-life'''
| align="center" style="background:#f0f0f0;"|'''Removed by HD'''
| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
|-
| [[Argatroban]]||40-50 min ||~ 20%||Turn off infusion
|-
| [[Bivalirudin]] (Angiomax®)||25 min (up to 1 hr in severe renal impairment)||~ 25%||As above
|-
| [[Dabigatran]]<ref>*Pradaxa prescribing information. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; January 2012.</ref> (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.
|}

===Heparins===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Anticoagulants'''
| align="center" style="background:#f0f0f0;"|'''Half-life'''
| align="center" style="background:#f0f0f0;"|'''Removed by HD'''
| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
|-
| [[Dalteparin]] (Fragmin®)||3-5 hrs (longer in renal impairment)||~ 20%||
*Use protamine for partial neutralization (~60%) 
*[[Protamine]] IV: 
**< 8 hours since last dose: [[Protamine]] 50mg 
**8-12 hours since last dose: [[Protamine]] 25mg 
**>12 hours since last 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 
|-
| [[Enoxaparin]] (Lovenox®)||3-5 hrs (longer in renal impairment)||~ 20%||As above
|-
| [[Unfractionated heparin]]||30-90 min (dose dependent)||Partial||
*Turn off infusion 
*[[Protamine]] 50mg IV
|}

===[[Warfarin]] (Coumadin®)===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''INR'''
| align="center" style="background:#f0f0f0;"|'''Clinical scenario'''
| align="center" style="background:#f0f0f0;"|'''Management'''
|-
| Any||Serious or life-threatening bleed||
*Hold [[warfarin]] 
*Give [[vitamin K]] 10mg IV infusion over 30 minutes 
*Give [[FFP]]/plasma or 
*Consider 4-factor [[PCC]] (Kcentra™)—preferred for life-threatening bleeds 
|-
| > 10||No bleeding||
*Hold warfarin until INR in therapeutic range 
*Consider [[vitamin K]] 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action) 
|-
| ||Rapid reversal required||
*Hold warfarin 
*Consider [[vitamin K]] 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action) 
|-
| 4.5-10||No bleeding||
*Hold warfarin until INR in therapeutic range 
*Consider [[vitamin K]] 2.5mg oral 
|-
| ||Rapid reversal required||
*Hold warfarin 
*Consider [[vitamin K]] 2.5mg oral or 1mg IV infusion (IV administration of vitamin K has faster onset of action) 
|-
| < 4.5||No bleeding||
*Hold warfarin until INR in therapeutic range
|-
| ||Rapid reversal required||
*Hold warfarin 
*Consider [[vitamin K]] 2.5mg oral
|}


==Medication Dosing==
<div style="display:none">
{{MedicationDose
| drug = Idarucizumab
| dose = 5g IV
| route = IV
| context = Dabigatran reversal
| indication = Anticoagulant reversal for life-threatening bleeds
| population = Adult
}}
{{MedicationDose
| drug = Protamine
| dose = 50mg IV (<8hr since last dose), 25mg (8-12hr)
| route = IV
| context = Heparin/LMWH reversal
| indication = Anticoagulant reversal for life-threatening bleeds
| population = Adult
| notes = Dose protamine for each 100 units dalteparin or 1mg enoxaparin
}}
{{MedicationDose
| drug = Vitamin K
| dose = 10mg IV over 30min
| route = IV
| context = Warfarin reversal with life-threatening bleed (INR >10)
| indication = Anticoagulant reversal for life-threatening bleeds
| population = Adult
}}
</div>

==See Also==
*[[Coagulopathy (main)]]
*[[Anti-platelet agent reversal]]

==External Links==
*[https://journalfeed.org/article-a-day/2019/anticoagulant-reversal-strategies-and-coi JournalFeed Summary with Flowsheet] of ”Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.” by Baugh et. al. from Annals 2019<ref>[https://www.ncbi.nlm.nih.gov/pubmed/31732375?dopt=AbstractPlus Baugh et al. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med. 2019 Nov 13. pii: S0196-0644(19)31181-3]</ref>

==References==
<references/>
*Harbor-UCLA Medical Center Guidelines Approved by Anticoagulation Subcommittee on 3/17/2016 Approved by Pharmacy and Therapeutic Committee on 3/17/2016
*Hatfield L and Chen SL. University of North Carolina Healthcare Anticoagulation Reversal Guidelines. June 2014.

[[Category:Heme/Onc]]