The advent of new oral anticoagulants (NOAC) has increased the armamentarium against
thromboembolic diseases but has given rise to a conundrum on their reversal. NOAC’s have
comparable efficacy to traditional vitamin K antagonists with similar rates of major bleeding. However
there is no standardized method for reversal of these agents and no specific antidote. This is of concern
not only in acute bleeding episodes but also in clinical scenarios where emergency surgery is required.
Recent studies have investigated reversal of dabigatran, rivaroxaban, and apixaban using prothrombin
complex concentrates (PCC), recombinant factor VIIa, and in the case of dabigatran, a monoclonal
antibody. These studies have been encouraging in showing improvement of bleeding times and blood
loss in most models, especially with the use of PCCs and the dabigatran antibody. Of note the majority of common
currently used coagulation assays may not correlate with clinical reversal. The management of overt bleeding with
NOACs is difficult due to the lack of clinical trials. Current animal trials, case reports and hemostatic testing on human
blood have shown some promise; provide guidance but warrant further investigation.
Keywords: Apixaban, dabigitran, new oral anticoagulants, reversal agents, reversal apixaban, reversal dabigitran, reversal of
oral anticoagulants, reversal rivaroxiban, rivaroxiban, target specific oral anticoagulants.
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