noacs and bleeding
TRANSCRIPT
![Page 1: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/1.jpg)
NOACs and Bleeding
Huy Tran
![Page 2: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/2.jpg)
Terminology
• NOAC– Novel oral anticoagulants– Non VKA oral anticoagulants– (NO Anticoagulation)
• DOAC– Direct oral anticoagulants
![Page 3: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/3.jpg)
Other Terms
![Page 4: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/4.jpg)
![Page 5: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/5.jpg)
• ODI– Oral Direct Inhibitors
• SODA– Specific Oral Direct Anticoagulant
• TSOAC– Target Specific Oral Anticoagulant
![Page 6: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/6.jpg)
Vote 2014
• DOAC 29.9%• NOAC 28.6%• TSOAC 23.4%
• North America and European• Australasia not asked to participate
![Page 7: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/7.jpg)
![Page 8: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/8.jpg)
![Page 9: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/9.jpg)
![Page 10: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/10.jpg)
New anticoagulants
Direct Thrombin Inhibitors
- Dabigatran
Factor Xa Inhibitors
- Rivaroxaban
- Apixaban
- Edoxaban
![Page 11: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/11.jpg)
![Page 12: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/12.jpg)
![Page 13: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/13.jpg)
![Page 14: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/14.jpg)
![Page 15: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/15.jpg)
![Page 16: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/16.jpg)
![Page 17: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/17.jpg)
![Page 18: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/18.jpg)
![Page 19: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/19.jpg)
![Page 20: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/20.jpg)
Management of Bleeding
• Prevention• Treatment
![Page 21: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/21.jpg)
Prevention of Bleeding
• Anticoagulant Selection• Patient and Dose Selection• Management of Interruption of Treatment
![Page 22: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/22.jpg)
![Page 23: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/23.jpg)
![Page 24: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/24.jpg)
-5 -4 -3 -2 -1 OR 1 2 3 4 5 6
DAYS
“No”: DVT prophylaxis with LMWH
or prophylactic dose of
NOAC
Post -Procedure Use of NOACs
Restart NOAC at
therapeutic doses
“Yes”: Restart NOAC at
therapeutic doses
Ask yourself: “Is it OK that the
patient be fully anticoagulated 2
hours after 1st dose?”
1
3
“No” Delay restart of DOAC at therapeutic
doses
2
![Page 25: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/25.jpg)
![Page 26: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/26.jpg)
![Page 27: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/27.jpg)
![Page 28: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/28.jpg)
![Page 29: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/29.jpg)
Reversal of NOACs
• Remove Drug• Active coagulation to overcome drug effect• Neutralise drug
![Page 30: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/30.jpg)
![Page 31: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/31.jpg)
![Page 32: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/32.jpg)
Pradaxa (Dabigatran) Reversal
![Page 33: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/33.jpg)
![Page 34: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/34.jpg)
![Page 35: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/35.jpg)
![Page 36: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/36.jpg)
![Page 37: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/37.jpg)
![Page 38: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/38.jpg)
Patients received 5 g of intravenous idarucizumab, which was administered as two 50-ml bolus infusions, each containing 2.5 g of idarucizumab, no more than 15 minutes apart. The 5-g dose was calculated to reverse the total body load of dabigatran that was associated with the 99th percentile of the dabigatran levels measured in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial.
*Pollack C, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015; 373:511-520.
![Page 39: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/39.jpg)
Approved and Available
![Page 40: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/40.jpg)
![Page 41: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/41.jpg)
![Page 42: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/42.jpg)
![Page 43: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/43.jpg)
![Page 44: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/44.jpg)
![Page 45: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/45.jpg)
• Cost- 5g is $US3500 (wholesale)
![Page 46: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/46.jpg)
*Siegal DM, et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015; 373:2413-2424 .
![Page 47: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/47.jpg)
![Page 48: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/48.jpg)
![Page 49: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/49.jpg)
![Page 50: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/50.jpg)
![Page 51: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/51.jpg)
![Page 52: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/52.jpg)
![Page 53: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/53.jpg)
![Page 54: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/54.jpg)
ANNEXA-4
• Phase III• 270 expected to be recruited• Jan 2015 to Nov 2022
![Page 55: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/55.jpg)
![Page 56: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/56.jpg)
![Page 57: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/57.jpg)
Local hemostatic measures
Hold 1 or more doses of dabigatran
Mild bleedingModerate-severe
Bleeding*Life-threatening
Bleeding*
Manage bleeding (compression, surgery)
Fluid diuresis Transfuse RBCs or
platelets if needed Oral charcoal if dose
<2 hrs before
If aPTT >40 sec, consult TE or Transfusion Medicine
When was last dose? FBE, creatinine aPTT, TT (dTT)
Patient with bleeding on dabigatran
Contact Transfusion Medicine
Tranexamic acid (1 G IV followed by 1 G infusion over 8 hours)
Hemodialysis might be helpful
Consider FEIBA**
![Page 58: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/58.jpg)
![Page 59: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/59.jpg)
Local hemostatic measures
Hold 1 or more doses of drug
Mild bleedingModerate-severe
Bleeding*Life-threatening
Bleeding*
Manage bleeding (compression, surgery)
Fluid diuresis Transfuse RBCs
or platelets if needed
Oral charcoal if dose <2 hrs before
If abnormal, consult TE or Transfusion Medicine
When was last dose? FBE, creatinine INR/anti-Xa level
Patient with bleeding on rivaroxaban/apixaban
Contact Transfusion Medicine
Tranexamic acid (1 G IV followed by 1 G infusion over 8 hours)
Consider FEIBA*/PCC
![Page 60: NOACS and bleeding](https://reader036.vdocuments.mx/reader036/viewer/2022070603/5871a6071a28abda6a8b4871/html5/thumbnails/60.jpg)
Future…