Reversal agents for oral anticoagulant-associated major or life-threatening bleeding

  • Marco Moia
  • Alessandro SquizzatoEmail author


Oral anticoagulants (OA) are effective drugs for treating and preventing the formation of blood clots in patients with atrial fibrillation, mechanical heart valves and venous thromboembolism but their therapeutic effect is always counterbalanced by an increased risk of bleeding. Direct oral anticoagulants (DOACs) have brought advantages in the management of many patients, with evidence of a lower risk of intracranial bleeding in comparison to vitamin K antagonists (VKAs). However, due to the increased number of anticoagulated patients worldwide, major and life threatening OA-related bleeding is also increasing, and effective reversal strategies are needed. We reviewed the reversal strategies for both VKAs and DOACs in the light of the latest evidence and recent guidelines, taking into account non-specific methods with fresh frozen plasma (FFP), prothrombin complex concentrate (PCC) or four factor PCC, as well as specific reversal antidotes that are already approved or in approval phase. Most published studies on OA reversal have drawbacks, such as lacking a control arm or data on clinically relevant outcomes, and current guidelines’ recommendations are mainly based on panellists’ judgment. There is an urgent need for well-designed studies in this field. In the meanwhile, to improve the correct use of available resources and patients’ outcomes, we suggest a seven-element bundle for an optimal management of OA-associated major bleeding, including the implementation of fast turnaround time for laboratory tests in emergency, i.e. INR and DOAC plasma levels, and to build up a ‘bleeding team’ that includes experts of hemostasis, lab, trauma, emergency medicine, endoscopy, radiology, and surgery in every hospital.


Bleeding Idarucizumab Andexanet Prothrombin concentrate complex Direct oral anticoagulant Vitamin K antagonist 



This article was independently developed by the authors following an advisory board meeting sponsored by Daiichi Sankyo SpA.

Compliance with ethical standards

Conflict of interest

Alessandro Squizzato received fees for lectures and advisory board meetings from Daiichi Sankyo, Pfizer, Bristol Myers Squibb, Bayer, Boehringer Ingelheim. Marco Moia received fees for lectures from Bayer, Daiichi Sankyo, Pfizer, Werfen.

Statements on human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study formal consent is not required.


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Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  1. 1.Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi VillaMilanItaly
  2. 2.Research Center on Thromboembolic Disorders and Antithrombotic TherapiesUniversity of InsubriaVareseItaly
  3. 3.U.O.C. Medicina GeneraleOspedale Sant’Anna - ASST LarianaSan Fermo della BattagliaItaly
  4. 4.Department of Medicine and SurgeryUniversity of InsubriaComoItaly

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