A new decision pathway that aims to guide the management of acute bleeding in patients treated with oral anticoagulants (OACs) was published Dec. 1 in the Journal of the American College of Cardiology.

The decision pathway supplements the 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation, and focuses on the management of bleeding in patients treated with direct OACs (DOACs) and vitamin K antagonists (VKAs) for any indication.

"DOACs are important medications in the management of clotting risk in a number clinical situations such as non-valvular atrial fibrillation and DVT/PE. These drugs are reasonably safe but bleeding is a well-known risk with some debate about best management," explains Gordon F. Tomaselli, MD, FACC, chair of the writing committee. "The article provides evidence-guided practical recommendations for management of bleeding in patients treated with OACs and is designed to be a living guide for the practitioner faced with a patient who experiences bleeding while being treated with an OAC."

The document includes algorithms on managing bleeds in patients on DOACs and VKAs with specific guidance on:

• assessing and defining bleed severity
• suggestions for laboratory measurement of the DOACs based on specialized assay availability
• managing major and non-major bleeds
• the options available for reversal of VKAs, dabigatran and Factor Xa inhibitors
• administering reversal agents based on the OAC prescribed to the patient
• the duration for withholding DOACs based on bleed risk
• available reversal agents and indications for each of the OACs
• considerations for when and whether a patient should resume anticoagulation therapy
• indications for anticoagulation with high-thrombotic risk
• situations in which it is recommended that the patient restart anticoagulation
• situations where it is recommended that a patient delay restart of anticoagulation; and
• important topics to discuss with patients prior to restarting anticoagulation.

"DOACs are commonly used for a variety of indications in clinical medicine and will likely increase in the future," adds Kenneth W. Mahaffey, MD, FACC, vice chair of the writing committee. "The recommendations in this article provide a pragmatic approach to the evaluation of bleeding; management of DOAC; use of reversal agents; and decision making about restarting DOACs after bleeding."

Moving forward, the writing committee concludes that "as more evidence is generated from ongoing research and clinical practice, further refinement to this decision pathway will be needed."

Keywords: Anticoagulants, Hemorrhage, Safety, Thrombosis, Factor Xa Inhibitors, Atrial Fibrillation, Consensus, Anticoagulants, Blood Coagulation, Vitamin K, Algorithms

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