As a hospital pharmacist, the new oral anticoagulants are bringing up questions about how to reverse bleeding due to Pradaxa or Xarelto. Antidotes for Pradaxa (dabigatran) or Xarelto (rivaroxaban) are NOT available in many hospitals, like vitamin K for warfarin. But there are things you can do.
Stopping the anticoagulant and waiting 1 to 2 days in patients with healthy renal function is enough prior to most surgeries. But this may not be fast enough for bleeding or emergency surgery. Follow these common-sense best practices to control bleeding. Start with activated charcoal to absorb any residual drug if a dose was taken within 2 hours. Maintain adequate diuresis, especially for Pradaxa since it's primarily renally excreted. Consider hemodialysis if feasible for Pradaxa, about 60% of the drug is removed in 2 to 3 hours. Xarelto is NOT dialyzable. Give red blood cells and fresh frozen plasma as appropriate. Consider activated prothrombin complex concentrates (aPCC) or recombinant factor VIIa as a last resort for life-threatening bleeding. There's not much evidence to support their use, and they increase thrombosis risk.
Keep in mind that clotting factors (fresh frozen plasma, aPCC, etc) aren't likely to be wholly effective. That's because these two anticoagulants INHIBIT clotting factors, they don't DEPLETE them. Be especially careful using Pradaxa or Xarelto in elderly patients with poor renal function, due to the higher risk of bleeding. For more data, read our note "Clinical pharmacology of DOACs".
REFERENCES
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van Ryn J, Stangier J, Haertter S, Liesenfeld KH, Wienen W, Feuring M, Clemens A. Dabigatran etexilate--a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost. 2010 Jun;103(6):1116-27. Available at: https://www.thieme-connect.de/products/ejournals/abstract/10.1160/TH09-11-0758
Patanwala AE, Acquisto NM, Erstad BL. Prothrombin complex concentrate for critical bleeding. Ann Pharmacother. 2011 Jul;45(7-8):990-9. Available at: https://journals.sagepub.com/doi/10.1345/aph.1Q096
Crowther MA, Warkentin TE. Managing bleeding in anticoagulated patients with a focus on novel therapeutic agents. J Thromb Haemost. 2009 Jul;7 Suppl 1:107-10. Available at: https://www.jthjournal.org/article/S1538-7836(22)17448-9/fulltext