Non-vitamin K oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban,
are increasingly used for thromboembolism prevention. Contrary to older anticoagulants, such as coumadin,
when antidotes existed and were broadly used in cases of emergent surgery and bleeding, antidotes for NOACs
have not been developed until recently. Moreover, the monitoring of NOAC’s anticoagulant effect varies across
different hospital settings and the absence of a single test that can accurately predict the degree of anticoagulation
achieved increases the uncertainty. These uncertainties often result in management dilemmas for clinicians when
patients who are on NOACs need a reversal of anticoagulation. Until recently, available antidotes for NOACs
included only prothrombin complex concentrate (PCC), activated prothrombin complex concentrate (aPCC) and
recombinant activated factor VII and the less optimal fresh frozen plasma (FFP). Recently though, novel antidotes
for NOACs have been developed, including idarucizumab, which is a monoclonal antibody fragment that binds
dabigatran, and andexanet alfa, a modified decoy form of the activated factor X (FXa) that binds FXa inhibitors
and AT III. Another option, ciraparantag, which is a small molecule that binds to heparin, thrombin inhibitors and
FXa inhibitors, is still in phase I development. In this review, we summarize the current evidence and present the
available bypassing and novel reversal agents. Finally, we propose an algorithm for the management of patients
who take NOACs and present to the emergency department with either trauma and active bleeding or need for
emergent surgery.
Prothrombin complex concentrate and recombinant prothrombin alone or in combination with recombinant factor X and FVIIa in dilutional coagulopathy: a porcine model