Table 3.

Guidelines for reversal of new oral anticoagulants.

Direct factor Xa inhibitors (FXa-Is)

(1)Discontinue FXa-I when ICH is present or suspected (good practice statement) (2)Pharmacological reversal of oral FXa-I should be guided primarily by bleeding (major or intracranial) and not primarily by laboratory testing (conditional recommendation, low-quality evidence) (3)Suggest administration of activated charcoal (50 g) to intubated ICH patients with enteral access and/or those at low risk of aspiration who present within 2 h of ingestion of an oral direct factor Xa inhibitor (conditional recommendation, very low-quality evidence) (4)Suggest administering a 4-factor prothrombin complex concentrate (PCC) (50 U/kg) or activated PCC (aPCC) (50 U/kg) if ICH occurred within 3–5 terminal half-lives of drug exposure or in the context of liver failure (conditional recommendation, low-quality evidence) (5)Suggest administering 4-factor PCC or aPCC over recombinant FVIIa (rFVIIa) because of the lower risk of adverse thrombotic events (conditional recommendation, low-quality evidence)

Direct thrombin inhibitors (DTIs)

(1)Discontinue DTI when ICH is present or suspected (good practice statement) (2)Pharmacological reversal of DTI should be guided primarily by bleeding (major or intracranial) and not primarily by laboratory testing (conditional recommendation, low-quality evidence) (3)Suggest administering activated charcoal (50 g) to intubated intracranial hemorrhage patients with enteral access and/or those at low risk of aspiration who present within 2 h of ingestion of an oral direct thrombin inhibitor (conditional recommendation, very low-quality evidence) (4)Recommend administering idarucizumab (5 g IV in two divided doses) to patients with ICH associated with dabigatran if dabigatran was administered: Within a period of 3–5 half-lives and there is no evidence of renal failure (strong recommendation, moderate quality of evidence) or There is renal insufficiency leading to continued drug exposure beyond the normal 3–5 half-lives (strong recommendation, moderate quality of evidence) (5)Suggest administering aPCC (50 U/kg) or 4-factor PCC (50 U/kg) to patients with ICH associated with DTI if idarucizumab is not available or if the hemorrhage is associated with a DTI other than dabigatran (6)In patients with dabigatran-associated ICH and renal insufficiency or dabigatran overdose, suggest hemodialysis if idarucizumab is not available (conditional recommendation, low-quality data) (7)In patients with dabigatran-associated ICH who have already been treated with idarucizumab, PCC, or aPCC, with ongoing evidence of clinically significant bleeding, we suggest consideration of redosing idarucizumab and/or hemodialysis (Conditional recommendation, low-quality evidence) (8)Recommend against administration of rFVIIa or FFP in direct thrombin inhibitor-related intracranial hemorrhage (strong recommendation, low-quality evidence)