Specific Measures According to the Anticoagulant/Antiplatelet Agent
| Anticoagulant/antiplatelet | Specific measures |
|---|---|
| Heparins | |
Unfractionated heparin by continuous IV infusion (half-life 1–2h) | Stop the infusion. For rapid reversal in major bleeding, give IV protamine sulphate. 1 mg protamine neutralizes 80–100 units of heparin. If the infusion has been stopped for 30 min or longer, give protamine 25 mg IV by slow injection over 10 min. If the infusion has only just been stopped, give protamine 50 mg IV by slow injection over 10 min. |
| Low-molecular-weight (LMW) heparin | Stop the LMW heparin. Check FBC, coagulation screen and fibrinogen. Check anti-Xa level. If last dose of LMW heparin was <8h, give protamine. 1 mg per 100 anti-Xa units of LMW heparin IV, by slow injection over 10 min. Consider rFVIIa if there is continued life-threatening bleeding despite protamine sulphate and the time-frame suggests there is residual effect from the LMW heparin contributing to bleeding. |
| Warfarin and other vitamin K antagonists | For rapid reversal in major bleeding or in head injury*, give prothrombin complex (contains factor IX, together with variable amounts of factors II, VII, and X), available from CSL Behring (Beriplex® P/N) and octapharma (Octaplex®)): give Beriplex or Octaplex 50units/kg (to a maximum single dose of Beriplex 5000 units or Octaplex 3000 units). Fresh frozen plasma produces suboptimal anticoagulation reversal and should only be used if prothrombin complex is not available. Give vitamin K 5–10 mg IV by slow injection. For non-major bleeding give 1–3 mg intravenous vitamin K (correction of the INR is seen within 6–8h; this has a faster time to effect than oral administration). |
| Direct-acting oral anticoagulants | |
| Dabigatran | Stop dabigatran and ascertain time of last dose. Seek advice from a haematologist. Consider use of PRAXBIND (idaracizumab): 5 mg bolus by IV injection. Consider use of PCC, APCC and rFVIIa. |
| Rivaroxaban/apixban | Stop drug and ascertain time of last dose. Seek advice from a haematologist. Consider use of PCC, APCC, rFVIIa. |
| Antiplatelet agents, for example aspirin, clopidogrel, ticagrelor | Transfuse 2–3 units of platelets. |
NB Protamine is contraindicated if the patient has fish allergy. Protamine can cause hypotension, bradycardia and anaphylaxis. At high concentration (if >50 mg administered), it has an anticoagulant effect.
* In head injury sufficient to cause facial or scalp laceration, bruising or haematoma, arrange for urgent CT head. If there is a suspicion of intracerebral bleed, reverse warfarin before the results of the CT head and INR are known. Even in patients with a normal CT head, a supra-therapeutic INR should be corrected with oral or IV vitamin K because of the risk of delayed bleeding.
Adapted from: British Society for Haematology.