bleeding and the NOACs

Question 1

What does it mean if on dabigatran and thrombin time normal?

Answer 1

Suggests levels of D are very low and bleeding risk similar to any patient

Question 2

How to manage a life threatening bleed on Dabigatran or Rivaroxaban

Answer 2

initiate standard resuscitation measures
Check INR, APTT, TCT, fibrinogen
Check renal function
Supportive measures- mechanical/surg/radiological intervention
Tranexamic acid (antifibrinolytic)
Consider charcoal binding if recent does (last 2 hours for dabigatran or 8 hours for rivaroxaban)
Consider dialysis
Talk to haematologist
Role of bypassing agents unclear
Need fluid replacement to maintain good urine output because renally cleared
Stop the agent and delay restarting until bleeding controlled

Question 3

How many doses/days held of NOACs pre-surgery?

Answer 3

Normal renal function and standard risk of bleeding- 24 hours both dab/riv/apix
Normal renal function and high risk bleeding- 2 days

If creat clearance less than 30 - dab 4 and 6 days for normal and high risk respectively, and riv/apix 2 and 4 days for normal and high risk

Question 4

Peak action of NOACS

Answer 4

1-3 hours for all

Question 5

Excretion % renal

Answer 5

Dab- primarily renal
Riv- 67% renal
Apix- 25% renal

Question 6

Monitoring levels

Answer 6

Dab- DILUTE thrombin time
Apix- anti Xa apix
Rivarox- anti Xa rivarox

Question 7

Do they prolong INR and APTT

Answer 7

yes all do

Question 8

Which ones indicated for stroke prevention in nonvalvular AF

Answer 8

Dab, apix, riv

Question 9

Which ones are indicated in thromboprophylaxis post hip and knee replacement

Answer 9

All three

Question 10

Which are indicated for treatment of acute DVT and prevention of DVT/PE

Answer 10

Rivarox

Question 11

What are the half lives?

Answer 11

Dabid 12-17 hours
Apix 9-14 hours
Riva 7-11 hours