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Home | Articles | Haematology and Thrombosis | Bleeding with Other Antithrombotics

Bleeding with Other Antithrombotics

Last updated 11th March 2022

Aspirin, Clopidogrel, Dipyridamole Prasugrel, Ticagrelor and Dual Therapies

  1. Stop administration of drug(s)
  2. Consider 1g Tranexamic acid IV
  3. If life threatening, give 2-3 units platelets

Alteplase, Tenecteplase, Reteplase, Streptokinase and Urokinase

  1. Stop infusion of fibrinolytic drugs and other antithrombotics
  2. Administer FFP 12ml/kg
  3. Administer tranexamic acid 1g tds IV
  4. Check fibrinogen – if there is depletion of fibrinogen, administer cryoprecipitate or fibrinogen concentrate

Apixaban, Edoxaban & Rivaroxaban

  1. Stop all antithrombotic drugs
  2. Check drug  level, if <25ng/ml bleeding unlikely to be related to drug
  3. For trivial/local bleeding – use local measures to control
  4. Moderate bleeding – Tranexamic acid 1g IV and blood product support
  5. Major life/limb/sight threatening – Tranexamic acid 1g IV, blood product support and Andexanet (discuss with Haematology)

Dabigatran

  1. Stop all antithrombotic drugs
  2. Check drug level, if <25ng/ml bleeding unlikely to be related to drug
  3. For trivial/local bleeding – use local measures to control
  4. Moderate bleeding – Tranexamic acid 1g IV and blood product support
  5. Major life/limb/sight threatening – Tranexamic acid 1g IV and blood product support and Idarucizumab (discuss with Haematology)
 

Unfractionated Intravenous Heparin

  1. Stop all antithrombotic drugs
  2. Not major bleeding (where reversal can wait 2 hours) – stop infusion and support patient
  3. Major or life/limb/sight threatening – stop infusion and give IV protamine 1mg per 80-110 units UFH administered in the previous two hours, max 50mg and no faster than 5mg/min

Low Molecular Weight Heparin (LMWH)

  1. Stop all antithrombotic drugs
  2. Not major bleeding – support patient
  3. Major or life/limb/sight threatening
    1. Give 1g Tranexamic acid IV
    2. Check anti-Xa level. If <0.1U/ml unlikely to be significant anticoagulation
    3. < 8 hours give 1mg IV protamine per 100 anti-Xa units of LMWH at infusion rate of 5mg/min with maximum dose of 50mg
    4. > 8 hours – give 0.5mg IV protamine per 100 anti-Xa units of LMWH at infusion rate of 5mg/min with maximum dose of 50mg
    5. Consider further doses of protamine if further bleeding
    6. Consider 90 microgrammes/kg recombinant FVIIa (NovoSeven) if life-threatening haemorrhage (discuss with Haematology)

Fondaparinux

  1. Stop all antithrombotic drugs
  2. Non-major bleeding – support patient
  3. Major or life /limb/sight threatening
    1. Give 1g tranexamic acid IV
    2. Check anti-Xa level – if <0.1U/ml unlikely to be significant anticoagulation present
    3. Consider 90 microgrammes/kg recombinant FVIIa (NovoSeven) if life-threatening haemorrhage (discuss with Haematology).

Andexanet

  1. Andexanet is a recombinant inactive factor X molecule. It is licensed for the reversal of Apixaban and Rivaroxaban in life-threatening bleeding. It is also likely to be effective in the reversal of Edoxaban.
  2. It is located in the ED drug cabinet in both DGRI and GCH. It can only be used after discussion with a Consultant Haematologist. Instructions for its administration are included with the drug.
DrugLast doseTiming of last dose
<8 hours or unknown≥8 hours
Apixaban≤5mgLow doseLow dose
>5mg or unknownHigh dose
Rivaroxaban≤10mgLow dose
>10mg or unknownHIgh dose
EdoxabanAny doseHigh dose
Initial IV bolusContinuous IV infusionTotal number of 200mg vials needed
Low dose400mg at 30mg/min4mg/min for 120 minutes5
High dose800mg at 30mg/min8mg/min for 120 minutes9

Idarucizumab

  1. Idarucizumab is a specific reversal agent for Dabigatran.
  2. It is located in the ED drug cabinet in both DGRI and GCH. It can only be used after discussion with a Consultant Haematologist. Instructions for its administration are included with the drug.
  3. The dose is 5g IV infusion given as two separate 2.5g doses each over 5-10 minutes.
  4. A further dose of 5g may be required if:
    • Recurrence of clinically relevant bleeding together with detectable Dabigatran levels, or
    • If potential re-bleeding would be life-threatening with detectable Dabigatran levels, or
    • Patients require a second emergency surgery/urgent procedure and have detectable Dabigatran levels.

Content by Dr Mark Crowther