Table 1.
Protocol for complete or partial reversal of antithrombotic drugs at OUH-U following trauma or TBI with severe bleeding.
| Drug to be reversed | Prerequisites | Agents | Doses |
|---|---|---|---|
| Vitamin K antagonist (VKA) | 1. Confirm drug indication 2. Take adequate coagulation tests* |
Prothrombin complex concentrate (PCC)** | According to matrix for body weight vs. INR, or 30 IU/kg iv. |
| Vitamin K1** | 5 mg iv. | ||
| Antiplatelet drugs | 1. Confirm drug indication 2. Define when last dose was administered 3. Take adequate coagulation tests* |
Desmopressin** Tranexamic acid** Add appropriate platelet transfusion** |
0.3 mcg/kg iv. 10 mg/kg iv. 1–2 units of 350 ml (360–720 × 109 platelets) |
| Direct oral anticoagulants (DOACs) | 1. Confirm drug indication 2. Define when last dose was administered 3. Take adequate coagulation tests* |
Reversal of dabigatran: - Idarucizumab*** |
5.0 g iv. |
| Reversal of apixaban, rivaroxaban, edoxaban: - Prothrombin complex concentrate (PCC)** |
If <15 h since last dose: 30 IU/kg iv. If 15–24 h since last dose: 20 IU/kg iv. |
||
| - Tranexamic acid** | 10–20 mg/kg iv. | ||
| - Andexanet alfa | Not available for use in Norway | ||
| Low molecular weight heparin (LMWH) | 1. Confirm drug indication 2. Take adequate blood samples |
Protamine sulfate** | If <12 h since last dose: 1 mg iv. per 100 IU dalteparin or per mg of enoxaparin. If 12–24 h since last dose: 0.5 mg iv. per 100 IU dalteparin or per mg of enoxaparin. |
Vitamin K antagonists (VKA) can be completely reversed by prothrombin complex concentrate (PCC) within minutes. Antiplatelet drugs can be reversed partially. Dabigatran (NOAC) can be reversed completely by Idarucizumab within minutes, while the other NOACs can be partly reversed by PCC and Tranexamic acid. Low molecular weight heparin (LMWH) can be partially reversed by Protamine sulfat. The potential benefit of reversal is weighed against any potential negative effect on an individual basis. The presence of mechanical heart valves (particularly in the mitral position) and recent stent implantation in major coronary vessels (left main stem, left anterior descending artery (LAD), bifurcation stenting) in particular merit careful consideration as acute heart valve thrombosis and thrombotic occlusion of proximal coronary vessels have high mortality rates.
INR, partial thromboplastin time (APTT), platelets, fibrinogen.
Available during the whole study period.
Available in Norway from January 1, 2016.