Factor Xa Inhibitor Reversal
| Anticoagulant
|
Half-life
|
Removed by HD
|
Strategies to reverse or minimize anticoagulant effects
|
| Apixaban (Eliquis®) |
8-15 hrs (longer in renal impairment) |
No |
- If ingested within 2 hours, administer activated charcoal
- 4-factor PCC (Kcentra™)^
- 25units/kg—max 2500 units for treatment of documented intracranial hemorrhage
- 50 units/kg—max 5000 units for all other life-threatening bleeds
|
| Edoxaban (Savaysa®) |
10-14 hrs (longer in renal impairment) |
~ 25% |
As above
|
| Rivaroxaban (Xarelto®) |
9-13 hrs (longer in renal impairment) |
No |
As above
|
| Fondaparinux (Arixtra®) |
17-21 hrs (significantly longer in renal impairment) |
No |
4-factor PCC (Kcentra™)^ 50 units/kg—max 5000 units
|
^Off-label
Direct Thrombin Inhibitor
| Anticoagulants
|
Half-life
|
Removed by HD
|
Strategies to reverse or minimize anticoagulant effects
|
| Argatroban |
40-50 min |
~ 20% |
Turn off infusion
|
| Bivalirudin (Angiomax®) |
25 min (up to 1 hr in severe renal impairment) |
~ 25% |
As above
|
| Dabigatran (Pradaxa®) |
14-17 hrs (up to 34 hrs in severe renal impairment) |
~ 65% |
- If ingested within 2 hours, administer activated charcoal
- Idarucizumab (Praxbind®) 5g IV
- For end stage renal disease patient with pre-existing vascular access, consult nephrology to consider dialysis.
|
Heparins
| Anticoagulants
|
Half-life
|
Removed by HD
|
Strategies to reverse or minimize anticoagulant effects
|
| Dalteparin (Fragmin®) |
3-5 hrs (longer in renal impairment) |
~ 20% |
- Use protamine for partial neutralization (~60%)
- Protamine IV:
- < 8 hours since last dose: Protamine 50mg
- 8-12 hours since last dose: Protamine 25mg
- >12 hours since last dose: Unlikely useful unless CrCl < 30 mL/min (or 25mg fixed dose)
- Dose of protamine for each 100 units dalteparin or 1mg of enoxaparin administered
- Obtain baseline anti-Xa activity level
- Monitor anti-Xa activity level to confirm reversal
|
| Enoxaparin (Lovenox®) |
3-5 hrs (longer in renal impairment) |
~ 20% |
As above
|
| Unfractionated heparin |
30-90 min (dose dependent) |
Partial |
|
| INR
|
Clinical scenario
|
Management
|
| Any |
Serious or life-threatening bleed |
- Hold warfarin
- Give vitamin K 10mg IV infusion over 30 minutes
- Give FFP/plasma or
- Consider 4-factor PCC (Kcentra™)—preferred for life-threatening bleeds
|
| > 10 |
No bleeding |
- Hold warfarin until INR in therapeutic range
- Consider vitamin K 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)
|
| |
Rapid reversal required |
- Hold warfarin
- Consider vitamin K 2.5mg oral or 1-2mg IV infusion over 30 minutes (IV administration of vitamin K has faster onset of action)
|
| 4.5-10 |
No bleeding |
- Hold warfarin until INR in therapeutic range
- Consider vitamin K 2.5mg oral
|
| |
Rapid reversal required |
- Hold warfarin
- Consider vitamin K 2.5mg oral or 1mg IV infusion (IV administration of vitamin K has faster onset of action)
|
| < 4.5 |
No bleeding |
- Hold warfarin until INR in therapeutic range
|
| |
Rapid reversal required |
|
See Also
External Links
References
- Harbor-UCLA Medical Center Guidelines Approved by Anticoagulation Subcommittee on 3/17/2016 Approved by Pharmacy and Therapeutic Committee on 3/17/2016
- Hatfield L and Chen SL. University of North Carolina Healthcare Anticoagulation Reversal Guidelines. June 2014.
- Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.
- Pradaxa prescribing information. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; January 2012.
- Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.
- Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.
