First guide for managing bleeding with NOACs

Recommendations include when to use reversal agents

The clinical problem of managing acute bleeding in patients taking anticoagulants is addressed in a new guidance by US cardiology experts.

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The evidence-based guidelines pertain to both non-vitamin K oral anticoagulants (NOACs), such as dabigatran, apixaban and rivaroxaban, and vitamin K antagonists (VKAs), such as warfarin.

The decision pathway considers the severity of the bleed (major vs non-major), the need for reversal, and the appropriateness and time of restarting anticoagulation.

Here are some of the main recommendations for controlling a major bleed:

  • Anticoagulants and antiplatelet agents should be held, and airway and large-bore intravenous access secured.
  • Reversal is recommended if an agent is available (see algorithm below), but obtaining and administering the reversal agent must not delay resuscitation and local haemostatic measures.
  • For patients with ongoing bleeding and/or haemodynamic instability, local measures to control bleeding such as pressure and packing should be combined with volume resuscitation.
  • Supportive measures should include blood product transfusion when appropriate.
  • Several options exist for reversal of VKAs, including administration of vitamin K, prothrombin complex concentrates, and plasma. Administration must be accompanied by a repletion strategy.
NOAC reversal algorithm
Source: Journal of the American College of Cardiology


For patients with a non-major bleed, routine reversal of the anticoagulant is not recommended, although it is often advisable to temporarily discontinue therapy until the patient is clinically stable and haemostasis has been achieved.

Read the full recommendations here