What is the most effective way to control bleeding in patients taking direct oral anticoagulants (DOACs)? Are reversal agents warranted in every case? These are among the key questions addressed during a lightning talk at Euroanaesthesia 2025.
As the global use of DOACs continues to rise, the need for clinicians to confidently manage associated bleeding complications has become paramount in both emergency departments and operating rooms. The reversal of DOACs plays a central role in treating life-threatening or major haemorrhage, and international guidelines now endorse the use of targeted reversal agents where appropriate. These include idarucizumab, approved for dabigatran reversal, and andexanet alfa, approved for reversing the effects of apixaban and rivaroxaban in cases of uncontrolled or life-threatening bleeding.
Despite these clear guidelines, clinical decision-making often varies depending on the individual patient and the clinical context. Christian von Heymann, Professor of anesthesiology and intensive care medicine at Charité Medical School, Humboldt University of Berlin, explains that there is no one-size-fits-all approach. The safe and effective management of DOAC-associated bleeding must consider both patient-specific and surgical factors. A co-author of the European guidelines on DOAC reversal in life-threatening bleeding, Prof von Heymann presented data from clinical trials supporting reversal strategies, including those used in cases of intracranial haemorrhage.
Reversal means neutralizing the effect of the anticoagulant, he explains. This is achieved through direct antidotes that specifically inhibit the anticoagulant’s action. In contrast, nonspecific haemostatic agents do not target the anticoagulant itself but may enhance overall coagulation function.
The first step in managing a bleeding patient on DOACs is a thorough clinical assessment to locate and gauge the severity of the bleed and to evaluate thromboembolic risk following reversal. Clinicians must determine whether the bleeding is life-threatening and requires immediate intervention, be it reversal or another non-hemostatic measure, despite the potential thromboembolic risks.
In emergency settings, where access to specific reversal agents may be limited, clinicians must act quickly using the tools at hand. Lidia Mora, associate professor of anesthesiology at Universitat Autònoma Barcelona and attending physician at Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, notes that when specific reversal agents are unavailable, the use of prothrombin complex concentrates is recommended and supported by existing evidence. However, many trauma studies are observational, which limits the strength of the recommendations.
Reversal decisions should be guided by the type of anticoagulant, its dose, and the timing of the last dose. While routine coagulation tests offer limited insights, advanced assays provide a more detailed picture of a patient’s haemostatic status. In emergency reversals, the goal is rapid access to the most accurate monitoring tools available. Conventional coagulation tests are insufficient for quantifying reversal. Instead, viscoelastic testing with DOAC-specific reagents and calibrated anti-Xa assays, especially for factor Xa inhibitors, should be prioritised. Conventional coagulation tests should be the last resort.
Dr Mora emphasised that clinicians must remain vigilant for bleeding complications in patients on oral anticoagulants and be prepared to act within the optimal therapeutic window. Integrating evidence-based recommendations into clinical workflows and leveraging available resources can help bridge the gap between guidelines and real-world practice, ensuring safer outcomes for patients experiencing DOAC-related bleeding emergencies.
Source: Euroanaesthesia 2025
Image Credit: iStock
