Properties and Antidotes for Anticoagulants Fibrinolytics

Direct Oral Anticoagulants (DOACs) for NVAF

UFH

• 60–90′, RES ↑ PTT
• Protamine IV 1 mg/100 U UFH (max 50 mg). For infusions, dose to reverse 2× UFH given per h.

LMWH

• 2–7°, K anti-Xa*
• Protamine reverses ~60%. 1 mg per 1 mg enox.

Bivalirudin

25′, K ↑ PTT Dialysis

Argatroban

45′, L ↑ PTT ? Dialysis

Warfarin

• 36°, L ↑ PT
• No bleeding: vit K 2.5 mg PO if INR >9, o/w no e/o clinical benefit (Blood Adv 2019;3:789)
• Bleeding: vit. K 10 mg IV + either 4F-PCC (KCentra, 25, 35, or 50 U/kg for INR 2–4, 4–6, or >6) or FFP 2–4 U IV q6–8h (slower, more volume)

Fibrinolytic

• 20′, LK ↓ fbgn
• Cryo, FFP, ± tranexamic or aminocaproic acid

Rivaroxaban Apixaban Edoxaban

• 8–12°, K >L ↑ PT* anti-Xa*
• Andexanet alfa (factor Xa decoy receptor): 800 mg bolus (30 mg/min) → 8 mg/min infusion (½ of above if taking ½ dose DOAC or ≥8 hrs since last dose; NEJM 2019;380:1326); 4F-PCC if andexanet not available

Dabigatran

• ~12°, K ↑ PTT*
• Idarucizumab: mAb binds drug (NEJM 2017;377:431)