ACUTE CARE 47: REVERSE ANTICOAGULATION THERAPY*

Warfarin and Novel Oral Anticogulant (NOAC) Reversal for Life-Threatening Bleeding

All patients taking Warfarin Patients taking direct factor Xa inhibitor, Patients taking direct thrombin
(eg, Apixaban or Rivaroxaban) inhibitor (eg, Dabigatran)

Any of the following: INR ≥ 2 and life -

- INR < 2 with life- threatening bleeding or
1. Transfuse RBCs to keep Hgb above 9 or 10
threatening bleeding reversal prior to
- Non-life-threatening bleed emergent surgery 2. After 4th U RBC start giving RBC: plasma on a 1:1 ratio
with INR >1.5 3. Cryo 10 U after 8th unit of RBCs, 4th U plasma (may not
- Reversal prior to non- need if fibrinogen is > 100 mg/dL)
emergent surgery, INR ≥ 2 4. If patient is on an anti-platelet drug (ASA, clopidogrel,
prasugrel, ticagrelor, aggrenox), give 2 U platelets in
1. KCentra† (PCC) unit/kg cases of life-threatening bleeding
Pre-treatment INR 2 – 3.9 4 – 6 >6
1. Transfuse thawed plasma – 15
Dose in units/kg 25 U/kg 35 U/kg 50 U/kg
mL/kg
Maximum Dose (U) 2500 3500 5000 Apixaban OR
2. Vitamin 10 mg IV X1
2. Vitamin K 10 mg IV x 1 Dabigatran
3. If patient is on anti-platelet Rivaroxaban
3. Vitamin K 2.5 to 5 mg IV x 1 If using Kcentra for 1. Consider idarucizumab
drug (ASA, clopidogrel, 1. KCentra (PCC)
emergent surgery where pt is at high risk for 5 g IV
prasugrel, ticagrelor, aggrenox) 50 U/kg IV X1
thrombosis or re-anticoagulation will be
give 2 U platelets if life- 2. Feiba (PCC) 50 U/kg IV
necessary shortly post surgery
threatening bleeding

Re-check INR in 30 minutes.

If bleeding is not controlled, consider recombinant activated
If INR >1.5,
factor VII 90 µg/kg IV x 1
transfuse additional plasma

† Kcentra contains heparin and cannot be used in patients with heparin allergy/HIT.

*Adapted with permission from Regions Hospital, St. Paul, Minnesota, 2017. August 2017

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