New Guidelines on Reversal of Anticoagulants in Patients with Intracranial Hemorrhage

January 17, 2017

New Guidelines on Reversal of Anticoagulants in Patients with Intracranial Hemorrhage

  1. Patricia Kritek, MD

Appropriate use of prothrombin complex concentrate and specific reversal agents are recommended.

  1. Patricia Kritek, MD

Sponsoring Organizations: Neurocritical Care Society (NCS) and Society of Critical Care Medicine (SCCM)

Target Audience: All critical care providers who care for patients with neurological emergencies

Background

NCS/SCCM brought together a 13-person international, multidisciplinary committee to provide guidance on managing patients with antithrombotic drug–associated intracranial hemorrhage (ICH).

Key Points

  • Vitamin K antagonists should be reversed. Suggested dosing is 10 mg vitamin K intravenously, to be repeated if international normalized ratio (INR) remains above 1.4 at 24 to 48 hours.

  • For patients with INR >1.4, administering three- or four-factor prothrombin complex concentrate (PCC) is recommended over using fresh frozen plasma.

  • If event occurred within 3 to 5 half-lives of drug administration, oral direct factor Xa inhibitors should be reversed with four-factor PCC, and dabigatran should be reversed with idarucizumab (Praxbind) if it is available (if not available, four-factor PCC should be used).

  • Patients who received therapeutic intravenous heparin should be treated with intravenous protamine at 1 mg for every 100 units of heparin administered in the past 2 to 3 hours (maximum dose, 50 mg). Protamine also is recommended for ICH if patients received low-molecular-weight heparin.

  • Cryoprecipitate should be administered to patients who have received thrombolytics.

  • Platelet transfusions are not recommended for patients who take antiplatelet agents, unless neurosurgical procedures are needed.

Comment

The level of evidence for most of these recommendations is relatively low, because experience with the new oral anticoagulants is still slowly growing. Emphasis is on targeted factor replacement (e.g., PCC and cryoprecipitate) and use of specific reversal agents (e.g., idarucizumab) when available. Andexanet alfa, a reversal agent for the anti–factor Xa drugs and enoxaparin, is not available yet but is undergoing FDA review (NEJM JW Gen Med Oct 1 2016 and N Engl J Med 2016; 375:1131).

Editor Disclosures at Time of Publication

  • Disclosures for Patricia Kritek, MD at time of publication Speaker’s Bureau American College of Chest Physicians (Critical Care Board Review Course)

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