Episode 89 – DOACs Part 2: Bleeding and Reversal Agents

This is EM Cases Episode 89 - DOACs Part 2: Bleeding and Reversal Agents. In Part 1 of this two part series on DOACs we talked about how DOACs work, their efficacy and safety compared to Warfarin, how to dose them, and when to avoid them. We also covered management of isolated calf DVTs, superficial vein thrombosis and anticoagulation in atrial fibrillation. In this Part 2, with Dr. Walter Himmel, Dr. Jim Douketis and Dr. Ben Bell, DOACs Bleeding and Reversal Agents we discuss the management of bleeding in patients taking DOACs with minor risk bleeds, like epistaxis where local control is easy to access, moderate risk bleeds, like stable GI bleeds and high risk bleeds, like intracranial hemorrhage. In DOACs Bleeding and Reversal we will answer questions such as: How do we weigh the risks and benefits of stopping the DOAC in minor, moderate and high risk bleeds? When is reversal of the DOAC is advised? How best do we accomplish the reversal of DOACs? Is there any good evidence for the newest reversal agent? When should we stop DOACs for different procedures, and when should we delay the procedure? Written Summary and blog post written by  Anton Helman December, 2016 Cite this podcast as: Helman, A, Himmel, W, Douketis, J, Bell, B. DOACs Part 2: Bleeding and Reversal Agents. Emergency Medicine Cases. December, 2016. https://emergencymedicinecases.com/aortic-dissection-em-cases-course/. Accessed [date]. Three categories of illnesses for bleeding risk in patients taking DOACs It is helpful to divide patients into low, moderate and high risk for poor outcomes from bleeding when considering whether to hold or stop DOACs. Low Risk: Bleeding where there is easy access to local bleeding control measures such as epistaxis and hemorrhoidal bleeding Moderate Risk: Stable GI bleed High Risk: Intracranial bleed, unstable GI bleed, bleeding into a closed space (eye, spinal cord, pericardium)   Case 1: Low Risk Bleed "Treat local problems with local solutions" An 89 year-old man with a history of atrial fibrillation and TIA on a DOAC for stroke prevention comes in with a few hours of brisk epistaxis that isn’t controlled with local pressure. You try some of the usual local maneuvers but the bleeding continues. His hemoglobin is normal. Would you stop the DOAC? Would you reverse the DOAC? Holding 1-2 doses of DOAC is akin to giving vitamin K to a warfarin-treated patient as vitamin K takes approximately 6-12 hours to take effect, similar to the approximate half life of the DOACs. Our experts recommend not stopping the DOAC in this case, as the patient likely has a high CHADS2 score and the increased risk of cardioembolic stroke would likely outweigh the risk of complications of the anticoagulation effect of the DOAC. Efforts to stop the bleeding should be centered on employing local methods such as wrapping a tampon in gelfoam or surgicel, a nasal balloon, applying ice to the palate (popsicles, ice in the mouth) which has been shown to reduce nasal blood flow up to 25%. For epistaxis, tonsillar or oral bleeding consider local application of 5% oral tranexamic acid solution (25mg of IV tranexamic acid solution) in addition to your local measures (soak gauze or surgicel or gelfoam in this solution and directly apply or swish and spit). Go to Episode 38: ENT Emergencies Pearls Pitfalls a...