Managing Bleeding With Anticoagulants

full update January 2025

This FAQ provides information to help clinicians manage and prevent bleeding with anticoagulants. Topics addressed include preprocedural/

presurgical washout, lab assessment of bleeding risk, reversal agents, management of nuisance bleeding, and restarting anticoagulants after a bleed.

Question

Answer/Pertinent Information

What preprocedural/presurgical washout is recommended for each anticoagulant?

(See footnote c regarding Thrombosis Canada guidance.)
  • Apixaban (Eliquis)
    • Last dose three days before surgery/procedure (i.e., 48-hour washout) with high bleeding risk (three to four days before if CrCl 15 to 29 mL/min).1,2
    • Last dose two days before surgery/procedure (i.e., 24-hour washout) with low/moderate bleeding risk (three days before if CrCl 15 to 29 mL/min).1,2
  • Dabigatran (Pradaxa)
    • Last dose three days before surgery/procedure (i.e., 48-hour washout) with high bleeding risk (five days before if CrCl <50 mL/min).2
    • Last dose two days before surgery/procedure (i.e., 24-hour washout) with low/moderate bleeding risk (three days before if CrCl 30 to 50 mL/min., four to five days before if CrCl 15 to 29 mL/min.).1,2
  • Dalteparin
    • Last therapeutic dose 24 hours before surgery/procedure at half the total daily dose (consider longer washout in kidney impairment).2,3
  • Edoxaban (Savaysa [US], Lixiana [Canada])
    • Last dose three days before surgery/procedure (i.e., 48-hour washout) with high bleeding risk (three to four days before if CrCl 15 to 29 mL/min).1,2
    • Last dose two days before surgery/procedure (i.e., 24-hour washout) with low/moderate bleeding risk (three days before if CrCl 15 to 29 mL/min).1,2
  • Enoxaparin
    • Last therapeutic dose 24 hours before surgery/procedure at half the total daily dose (consider longer washout in kidney impairment).2,3
  • Fondaparinux
    • At least five days if complete clearance is desired (half-life 17 to 21 hours in normal kidney function).4
    • UFH
    • Stop infusion four to six hours before procedure.2
  • Rivaroxaban (Xarelto)
    • Last dose three days before surgery/procedure (i.e., 48-hour washout) with high bleeding risk (three to four days before if CrCl <30 mL/min).1,2
    • Last dose two days before surgery/procedure (i.e., 24-hour washout) with low/moderate bleeding risk (three days before if CrCl<30 mL/min).1,2
  • Warfarin
    • Five days, or longer in certain patients, depending on age, comorbidities, warfarin dose, and baseline INR.2

What blood tests might help assess the patient’s anticoagulant-associated bleeding risk?
  • DOACs
    • DOAC plasma levels
      • DOAC levels are expensive, not widely available, and the result may not be available in time to use for decision-making (e.g., administration of reversal agent).2
      • Limited data suggest that DOAC levels <30 to 50 ng/mL are not associated with increased surgical bleeding risk.2
      • Apixaban or edoxaban reversal is suggested for patients with serious bleeding and a level >50 ng/mL, and for patients requiring high bleeding risk surgery/procedure and a level >30 ng/mL.5
      • There is not enough information to recommend checking DOAC levels routinely pre-op, especially before elective surgery in patients in whom the DOAC was held pre-op.2
    • Anti-factor Xa levels calibrated to LMWH below the limit of detection probably excludes a clinically important effect of apixaban, edoxaban, and rivaroxaban.5 Anti-factor Xa activity calibrated to apixaban, edoxaban, or rivaroxaban are more sensitive and correlate with drug levels.2,5
    • A normal aPTT does not rule out a clinically important effect of apixaban, edoxaban, or rivaroxaban, and may not rule out a clinically important dabigatran effect, depending on reagent sensitivity.5
    • A normal PT/INR does not rule out a clinically important apixaban, edoxaban, or rivaroxaban effect.5,14 A prolonged PT suggests a clinically important apixaban, edoxaban, or rivaroxaban effect.5
    • Normal thrombin time or ecarin clotting time probably rules out clinically important dabigatran levels.5,14
  • Dalteparin, enoxaparin, and UFH:7
    • aPTT (heparin)
    • anti-factor Xa activity
  • Fondaparinux
    • anti-factor Xa activity7
  • Warfarin
    • INR6

What are the reversal options for oral direct factor Xa inhibitors (apixaban, edoxaban, and rivaroxaban)?
  • Activated charcoal can be considered for:
    • Apixaban: within two to four hours (perhaps up to six hours) after apixaban ingestion.5,8,9
    • Edoxaban: within two to four hours after edoxaban ingestion.5
    • Rivaroxaban: within two to four hours after rivaroxaban ingestion (up to eight hours after an overdose).5,10
  • Dialysis is is NOT expected to be an effective reversal method for apixaban, edoxaban, or rivaroxaban.6
  • Reversal options based on case reports/case series/chart review are:
    • 4-factor PCC:
      • Kcentra [US]: a fixed dose of 2,000 units may be as effective as 50 units/kg [Evidence level B-3].11,e
      • Octaplex or Beriplex [Canada]: 25 to 50 units/kg (max 3,000 units), or 2,000 units.14,30
  • Andexanet alfa (Andexxa [US]; Ondexxya [Canada]), is approved for reversal of apixaban or rivaroxaban in the event of life-threatening or uncontrolled bleeding.15,16 (The high-dose regimen [see labeling] could be considered off-label for edoxaban reversal, but it has been studied only in a limited number of patients and healthy volunteers.5,17) For more information on andexanet alfa, see footnote a.

What are the reversal options for dabigatran?
  • Consider activated charcoal within two to four hours after dabigatran ingestion.5
  • Reversal options based on limited animal, in vitro, and single-arm cohort studies:30
    • 4-factor PCC:
      • Kcentra [US]:50 units/kg, max 4,000 units.5,13
      • Octaplex, Beriplex [Canada]: 25 to 50 units/kg (max 3,000 units), or 2,000 units.30
    • activated PCC (FEIBA NF): 50 units/kg, max 4,000 units (Canada: max 2,000 units. If weight unknown, give
      2,000 units.)5,13,30
    • They have variable benefit on hemostatic parameters.5
  • Idarucizumab (Praxbind), is approved for reversal before emergency surgery or urgent procedures, or with life-threatening or uncontrolled bleeding.22,23 For more information about idarucizumab, see footnote b.

What are the reversal options for dalteparin?
  • Within eight hours of administration, 1 mg protamined for each 100 units of dalteparin (or 50 mg) can be given.7,32 Max single dose 50 mg.32 Reduce the protamine dose by 50% if it has been eight to 12 hrs since the last dalteparin dose (max 25 mg).7,32 If it has been >12 hrs since the last dalteparin dose, protamine is unlikely to be effective (except perhaps in kidney impairment33), but protamine 25 mg could be given.7
  • If bleeding persists after two to four hours, a dose of protamine 0.5 mg for each 100 units of dalteparin should be given.6,32
  • Be aware that aPTT may remain prolonged after treatment.6 Do not expect anti-Xa activity to be completely neutralized by protamine (max 60% to 75%).6

What are the reversal options for enoxaparin?
  • Within eight hours of administration, 1 mg protamined for each 100 units of dalteparin (or 50 mg) can be given.7,32 Max single dose 50 mg.32 Reduce the protamine dose by 50% if it has been eight to 12 hrs since the last dalteparin dose (max 25 mg).7,32 If it has been >12 hrs since the last dalteparin dose, protamine is unlikely to be effective (except perhaps in kidney impairment33), but protamine 25 mg could be given.7
  • If bleeding persists after two to four hours, a dose of 0.5 mg protamine for each 1 mg of enoxaparin should be given.6,32
  • Be aware that aPTT may remain prolonged after treatment.6 Do not expect anti-Xa activity to be completely neutralized by protamine (max 60% to 75%).6
  • Only twenty enoxaparin patients were included in the ANNEXA-4 study. Andexanet alfa not FDA-approved for enoxaparin reversal.15,18

What are the reversal options for fondaparinux?
  • Consider factor VIIa (NovoSeven) 90 mcg/kg.7,32
  • Factor VIIa will not affect fondaparinux anti-factor Xa activity.7

What are the reversal options for heparin (unfractionated)?
  • UFH infusion: protamine 1 mgf neutralizes 100 units of heparin (e.g., a 5,000-unit intravenous heparin bolus is neutralized by 50 mg of protamine). Due to heparin’s short half-life (30 to 120 minutes34), when given by continuous intravenous infusion, only UFH administered in the past few hours needs to be neutralized.32 Example:6,32
    • For a UFH dose of 1,000 units/hr, protamine 10 mg will neutralize the heparin administered in the past hour, 5 mg will neutralize the dose received the hour before, and 2.5 mg will neutralize the dose received the hour before that (total dose = 17.5 mg).6 Max dose is 50 mg.32
  • Subcutaneous UFH: protamine 1 mg neutralizes 100 units of heparin. Check aPTT every three hours and repeat protamine 0.5 mg per 100 units heparin if bleeding continues.35

What are the reversal options for warfarin?
  • For major bleeding with INR >1.5, or intracranial hemorrhage with INR ≥1.3, use 4-factor prothrombin complex concentrate plus vitamin K as an adjunct.5,30,36
    • Vitamin K 5 to 10 mg by slow IV infusion is given to maintain factor levels after 4-factor prothrombin complex concentrate effects wear off.6
    • Vitamin K should be diluted in 25 to 50 mL normal saline and infused over 15 to 30 minutes. IV is more predictable and faster than oral (four to six hours vs 18 to 24 hours for oral).5
    • See 4-factor prothrombin complex concentrate (Kcentra [US], Octaplex [Canada], Beriplex [Canada]) labeling for weight- and INR-based dosing for warfarin reversal.

OR

      • Canada: see dosing recommendations from the National Advisory Committee on Blood and Blood Products at https://nacblood.ca/en/resource/recommendations-use-prothrombin-complex-concentrates-canada. Dose will be 1,000 to 3,000 units for adults, depending on INR (and weight, if known).30 If INR is unknown, a fixed dose of 2,000 IU can be given for severe bleeding.30
      • US: for life-threatening or critical site bleeding, consider a fixed dose of 1,000 units, or 1,500 units for an intracranial hemorrhage.5*,e A dose of 2,000 units may be optimal, especially if weight is >100 kg or if INR is >7.5).12,37*
        • Consider an additional 500 units in 15 to 30 minutes if INR or hemostasis goal is not met.59,*
        • For intracranial hemorrhage, if INR is 1.3 to <2, some experts suggest a lower dose of 10 to 20 units/kg to limit VTE risk.36
    • Use fresh frozen plasma if 4-factor prothrombin complex concentrate is not available.5

*Dosing based on Kcentra (US).

What strategies can be used to maximize benefit while minimizing bleeding risk for patients who need an anticoagulant?
  • Avoid switching from anticoagulants to aspirin in A-fib patients.38 Aspirin is less effective at preventing strokes and may not cause less bleeding.38
  • Ask patients if they take any supplements; some can increase bleeding risk (e.g., fish oil, garlic, ginkgo). Search our Natural Med Pro database to identify others.
  • Re-evaluate the need for medications that could increase bleeding risk (e.g., SSRIs, NSAIDs).
  • Assess continued need for concomitant antiplatelets (e.g., aspirin for primary prevention).5
    • Limit anticoagulant/antiplatelet combinations to evidence-based regimens and durations.See our chart, Combination Antithrombotic Therapy. Ensure that the intended stop date (if applicable) for antiplatelet prescriptions is communicated to the patient, outpatient prescriber, and pharmacist to avoid using it longer than necessary.
  • Recommend consistent vitamin K intake for patients taking warfarin.38
  • Control blood pressure but avoid hypotension due to fall risk.39
  • Ensure patients are aware to look for signs/symptoms of bleeding and know when/how to report/manage them (see below).
  • See our toolbox, Appropriate Use of Anticoagulants for more safety tips pertaining to metabolic drug interactions, gastroprotection, anticoagulant choice, modifiable risk factors, etc.

How should bleeding be managed in the outpatient setting?
  • Nuisance bleeding in A-fib patients is not associated with risk of major bleed over six months, and therefore does not automatically require alteration to the antithrombotic regimen.40
    • Symptoms that might prompt non-urgent evaluation of the antithrombotic regimen include frequent nosebleeds (three or four in a week or six in a month); menstrual bleeding that is a little heavier or longer than usual; a little blood on toilet paper after a bowel movement without additional symptoms.41,42
      • For patients with heavy menstrual bleeding, consider LNG-IUD, tranexamic acid, or DMPA.43
      • Consider checking the INR in patients taking warfarin.(There is no lab test available, like the INR, for monitoring the therapeutic efficacy of DOACs.)
    • Give patients tips to reduce their risk of nuisance bleeding: prevent constipation; keep the nose moist with nasal saline and petroleum jelly (especially in nasal steroid users); use a soft-bristle toothbrush and waxed floss; shave with an electric razor.41,42,44
  • Ensure that patients understand what kind of bleeding is worrisome and requires immediate medical attention. Examples include:
    • any bleeding with dizziness, lightheadedness, rapid heart rate, fatigue, shortness of breath, or chest pain.41,42
    • nosebleeds that do not stop within 30 minutes of self-treatment (e.g., sit up, lean forward, and pinch the soft part of the nose under the bridge for 10 to 15 min., +/- oxymetazoline nasal spray), or nosebleeds with blood pouring down the back of the throat.41,45
    • rectal bleeding resulting in tarry or bloody stool, or bright red blood in the toilet.42
    • urinary bleeding.42
    • vaginal bleeding that soaks a pad or more an hour, for more than two hours.42
    • cuts that are large, deep, dirty, or bleeding heavily (e.g., bleeding that doesn’t stop within 30 minutes with self-treatment [e.g., hold pressure with a clean gauze for 15 minutes; elevating cut above the heart, then use of a hemostatic like a styptic pencil if needed]).46
    • vomiting or coughing up blood.44
  • For patient information on managing nosebleeds, bruises, and minor cuts, see https://anticoagulationtoolkit.org/patients. This resource also has a link to a video on home management of nosebleeds. Another source of patient information on nosebleed prevention and treatment is available at: https://bpb-us-e1.wpmucdn.com/sites.uw.edu/dist/8/9473/files/2022/11/Preventing_Treating_Nosebleeds_1_10.pdf.

Which patients should receive VTE prophylaxis during an admission for a major bleed?
  • In general, for patients who are bleeding, but who otherwise qualify for VTE prophylaxis, intermittent pneumatic compression +/- graduated compression stockings are suggested.47 Pharmacologic VTE prophylaxis is suggested once bleeding risk decreases, if VTE risk persists.47
  • In patients hospitalized for an active GI bleed, individualize decisions, taking into account the patient’s thrombosis risk factors and bleeding risk.5,49 Avoid pharmacologic VTE prophylaxis in the first 24 hours of ICU admission for a lower GI bleed, due to increased transfusions and length of ICU stay.48
  • For patients with spontaneous intracerebral hemorrhage, start VTE prophylaxis with intermittent pneumatic compression on day one of admission (graduated compression stockings don’t work in these patients).50 Prophylactic dose LMWH or UFH can be considered starting 24 to 48 hours post-event in patients who are nonambulatory.50

When should oral anticoagulants be restarted after a major bleed?

General considerations

  • First, consider whether restarting the anticoagulant is still indicated. Consider not restarting anticoagulation in patients with nonvalvular A-fib and a CHA2DS2-VASc score (see footnote f) <2 in men or <3 in women; a temporary indication (e.g., post-op prophylaxis; anterior myocardial infarction without left ventricular thrombus; post-left atrial appendage closure device placement); recovered acute stress cardiomyopathy; first provoked VTE (after three months); bioprosthetic valve without A-fib (after three months).5 Also assess continued need for concomitant antiplatelets (e.g., aspirin for primary prevention).5 Limit anticoagulant/antiplatelet combinations to evidence-based regimens and durations. See our chart, Combination Antithrombotic Therapy.
  • Consider patient values and preferences.1
    • Advise patients that the benefits of anticoagulation usually the outweighs risk after a GI bleed.5 Evidence from warfarin-treated patients suggests that restarting after an intracranial hemorrhage decreases thrombosis risk and mortality without increased risk of recurrent bleeding.5 (Note that lobar ICH due to amyloid angiopathy and spontaneous subdural hematoma pose higher rebleeding risk.5)
    • For help with risk/benefit discussion with A-fib patients, see the American College of Cardiology’s A-fib decision aid resources at https://www.cardiosmart.org/topics/decisions.
  • Before the anticoagulant is restarted, check for drug interactions or incorrect dosing that may have played a role in the bleed.5
  • The decision regarding timing of re-institution should ideally be made by a multidisciplinary team.5
  • Parenteral anticoagulation can usually be restarted, with close monitoring, within one to three days of the bleed.5

GI bleeding

  • Restart in ~7 days, and within 14 days to reduce thrombosis risk.5,51,52
  • Generally, add a PPI (also see below).52

Intracerebral hemorrhage

  • Anticoagulation for nonvalvular A-fib after intracerebral hemorrhage can be considered after weighing risk vs mortality benefit. A DOAC may be a safer choice than warfarin.50
  • The best time to restart oral anticoagulation after anticoagulant-associated intracerebral hemorrhage is unclear.50
    • Avoiding oral anticoagulation for about seven to eight weeks in patients with A-fib might provide net benefit in regard to stoke risk reduction vs bleeding risk.50,30
    • For patients with mechanical heart valves, restarting as soon as day six (e.g., in a patient with a small bleed) to day 14 could be considered.50
    • Forpatients with a left ventricular assist device, restarting as soon as day 14 could be considered.50
    • Waiting ≥8 to 10 weeks after an intracerebral bleed may be appropriate for patients with a high bleeding risk
      (e.g., large bleed, brainstem or cerebellar intracerebral hemorrhage).50

When should GI prophylaxis be considered?
  • Consider a PPI for primary prevention in patients at high bleeding risk (See our toolbox, Appropriate Use of Anticoagulants).
  • Add a PPI after an upper GI bleed.52,53
  • Avoid PPIs for the management of lower GI bleeding.54

Which oral anticoagulants are preferred after a major bleed?
  • Apixaban seems to pose a lower risk of upper GI bleeding than rivaroxaban, dabigatran, or warfarin.55,56
  • DOACs have a lower risk of intracranial hemorrhage compared to warfarin in A-fib patients with an absolute risk of intracranial hemorrhage of 0.52% (dabigatran), 0.78% (rivaroxaban), 0.52% (apixaban), and 1.24% (warfarin).57
  • Continue to use warfarin in patients with mechanical valves.58

What if anticoagulation is not restarted prior to discharge?
  • Provide patients with a “to-do” list with detailed instructions to ensure anticoagulation is restarted at the appropriate time and that follow-up with the provider managing anticoagulation is scheduled.
  • Ensure the plan for restarting is communicated to the outpatient provider (e.g., addressed in the discharge summary).
  • Provide a post-discharge follow-up call to the patient to ask about anticoagulation therapy and follow-up.

How should anticoagulation monitoring be enhanced following a major bleed?
  • For DOACs, ensure dosing is appropriate for indication, age, weight, liver function, and kidney function. See our chart, Comparison of Oral Anticoagulants.
  • Ensure patients are aware to look for signs/symptoms of bleeding and know when/how to report them (see above).
  • For warfarin, consider increased INR monitoring, targeting the lower end of the therapeutic INR range, and referral to an anticoagulation clinic.
  1. Andexanet alfa: In an open-label study, 82% of patients had good or excellent hemostasis at 12 hours, with some achieving hemostasis within one hour.18,19 Use poses risk of infusion reactions (18%) and thrombosis (10%; restart anticoagulation as soon as appropriate).15,16,29 Despite some cohort data suggesting lower mortality, other evidence does not support superiority of andexanet alfa over usual care (e.g., 4-factor PCC) in regard to meaningful clinical benefit, and it may pose a higher thrombosis risk.20,21,25-27,29,31 In ICH, it seems to restore hemostasis faster than usual care, but increases ischemic stroke and perhaps MI risk without improving survival or functional status.20,29 Consider for patients with severe bleeding and no history of thromboembolic events, or ICH with early presentation and rapid bleed expansion.20,30 Prep/administration time is longer than for 4-factor PCC.27
  2. Idarucizumab: Generally preferred over PCC although proof of superiority is lacking.28,30,31 Cohort data suggest complete reversal of dabigatran’s effect on clotting tests within four hours. Median time to hemostasis in bleeding patients was 2.5 hours (secondary endpoint). Median time to initiation of surgery/invasive procedure was 1.6 hours [Evidence level B-3].24 Use poses 4% to 5% risk of thrombosis.28 Dabigatran can be restarted as soon as 24 hrs after idarucizumab.15,16
  3. Recommendations in chart may differ from Thrombosis Canada guidelines: https://thrombosiscanada.ca/clinical_guides/pdfs/PERIOPERATIVEMANAGEMENTOFPATIE_81.pdf.
  4. Protamine adverse effects include hypotension and bradycardia, which can be minimized by slow IV administration (5 mg/min).6,32 Anaphylaxis may also occur.6 Pretreatment with corticosteroids and diphenhydramine may be considered for patients with risk factors for anaphylaxis (e.g., fish allergy, vasectomy [protamine is derived from fish sperm], exposure to protamine-containing insulin).6
  5. Fixed dose Kcentra appears to safer and more effective, costs less, and gets to the patient faster than weight-based dosing for factor Xa-inhibitor and warfarin reversal.37
  6. CHA2DS2-VASc score: CHF = 1 point; Hypertension = 1 point; Age 75 or older = 2 points; Diabetes = 1 point; prior Stroke, TIA, or thromboembolism = 2 points; Vascular disease (aortic plaque, peripheral artery disease, or history of MI) = 1 point; Age 65 to 74 years = 1 point; Sex category female = 1 point.28 An online calculator is available at https://www.mdcalc.com/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk.

Abbreviations: ACT = activated clotting time; A-fib = atrial fibrillation; DMPA = depot medroxyprogesterone acetate injection; CrCl = creatinine clearance; DOAC = direct-acting oral anticoagulant; GI = gastrointestinal; ICH = intracranial hemorrhage; ICU = intensive care unit; INR = international normalized ratio; IV = intravenous; LNG-IUD = levonorgestrel-releasing intrauterine device; LMWH = low-molecular-weight heparin; NSAID = nonsteroidal anti-inflammatory drug; PCC = prothrombin complex concentrate; PPI = proton pump inhibitor; SSRI = selective serotonin reuptake inhibitors; UFH = unfractionated heparin; VTE = venous thromboembolism.

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*
  1. High-quality randomized controlled trial (RCT)
  2. Systematic review (SR)/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*
  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]

References

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  2. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022 Nov;162(5):e207-e243.
  3. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017 Feb 21;69(7):871-898.
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  6. Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2024. http://www.clinicalkey.com. (Accessed January 8, 2025).
  7. University of Washington. Guidelines for reversal of anticoagulants. April 2020. https://bpb-us-e1.wpmucdn.com/sites.uw.edu/dist/8/9473/files/2020/10/GUIDELINES-FOR-REVERSAL-OF-ANTICOAGULANTS.pdf. (Accessed January 11, 2025).
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  9. Product monograph for Eliquis. Pfizer Canada. Kirkland, QC H9J 2M5. October 2019.
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  11. Castillo R, Chan A, Atallah S, et al. Treatment of adults with intracranial hemorrhage on apixaban or rivaroxaban with prothrombin complex concentrate products. J Thromb Thrombolysis. 2021 Jan;51(1):151-158. Erratum in: J Thromb Thrombolysis. 2021 Jan;51(1):246.
  12. Bitonti MT, Rumbarger RL, Absher RK, Curran LM. Prospective Evaluation of a Fixed-Dose 4-Factor Prothrombin Complex Concentrate Protocol for Urgent Vitamin K Antagonist Reversal. J Emerg Med. 2020 Feb;58(2):324-329.
  13. Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019 Jun;94(6):697-709.
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  17. Benz AP, Xu L, Eikelboom JW, et al. Andexanet Alfa for Specific Anticoagulation Reversal in Patients with Acute Bleeding during Treatment with Edoxaban. Thromb Haemost. 2022 Jun;122(6):998-1005.
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Cite this document as follows: Clinical Resource, Managing Bleeding with Anticoagulants. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. January 2025. [410168]


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