Title:Direct (New) Oral Anticoagulants (DOACs): Drawbacks, Bleeding and Reversal
Volume: 20
Issue: 2
Author(s): Ozgur Karcioglu*, Sehmus Zengin, Bilgen Ozkaya, Eylem Ersan, Sarper Yilmaz, Goksu Afacan, Derya Abuska, Mandana Hosseinzadeh and Selman Yeniocak
Affiliation:
- Department of Emergency Medicine, University of Health Sciences, Istanbul Education and Research Hospital, Istanbul,
Turkey
Keywords:
Direct oral anticoagulants, bleeding, hemorrhage, dabigatran, rivaroxaban, edoxaban, idarucizumab, andexanet alfa, prothrombin complex concentrate.
Abstract:
Background and Objective: Direct (new) Oral Anticoagulants (DOACs) have emerged
as a contemporary and promising option in the treatment of thromboses and VTE, while protecting
the coagulation cascade against untoward bleeding events. They are used in the management and
prophylaxis of Venous Thromboembolism (VTE) and other thrombotic diseases. The most prominent
complication of these agents is bleeding. These agents have similar or lower rates of major intracranial
hemorrhages, while they had a higher risk of major gastrointestinal bleeding when compared
to warfarin. This manuscript is aimed to revise and update the literature findings to outline
the side effects of DOACs in various clinical scenarios.
Methods: A narrative review of currently published studies was performed. Online database searches
were performed for clinical trials published before July 2021, on the efficacy and adverse effects
attributed to the anticoagulant treatment, especially DOACs. A literature search via electronic
databases was carried out, beginning with the usage of the agents in the Western Languages papers.
The search terms initially included direct (new) oral anticoagulants, dabigatran, rivaroxaban,
apixaban, edoxaban, idarucizumab, andexanet, prothrombin complex concentrates, and fresh
frozen plasma. Papers were examined for methodological soundness before being included.
Results: Severe bleeding episodes require aggressive interventions for successful management.
Therefore, bleeding should be evaluated in special regard to the location and rate of hemorrhage,
and total volume of blood loss. Patient's age, weight and organ dysfunctions (e.g., kidney/liver failure
or chronic respiratory diseases) directly affect the clinical course of overdose.
Conclusion: Management recommendations for hemorrhage associated with DOAC use vary, depending
on the class of the culprit agent (direct thrombin inhibitor vs. FXa inhibitor), the clinical
status of the patient (mild/ moderate vs. severe/life-threatening), and capabilities of the institution.
Specific reversal agents (i.e., idarucizumab and andexanet alfa) can be used if available, while prothrombin
complex concentrates, fresh frozen plasma and/ or tranexamic acid can also be employed
as nonspecific replacement agents in the management of DOAC-related bleeding diathesis.
