EM in 5: NOACs – Novel Oral Anticoagulants

Author: Anna Pickens, MD (@AnnaEMin5, Creator of EM in 5) // Edited by: Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit), and Manpreet Singh, MD (@MprizzleER)

emDOCs would like to introduce a new series in association with creator and founder of EM in 5, Dr. Anna Pickens! We will be hosting videos from Dr. Pickens with links to further reading to provide focused visual and audio learning for those with a short time to obtain what you need for your next shift.

Video 

NOACs

Novel oral anticoagulants, serve as an alternative to warfarin.

• Two types: Direct thrombin inhibitors (dabigatran) and Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban), which work on several components of the coagulation cascade:

• Uses: Atrial fibrillation, DVT, PE
• Advantages: Less drug-drug interaction, less dietary restrictions, more predictable pharmacokinetics
• Disadvantages: Greater difficulty with reversal if needeD

Reversal

Reversal can be difficult. What are your options?

• Do everything else you can (general measures): determine time of last NOAC dose, mechanical compression, two sites of IV access, labs (CBC, BUN, Cr, LFTs), transfuse if needed, activated charcoal if ingestion within 2 hours, consult hematology/IR/Surgery.
• Consider adjuncts: FFP, pRBCs, platelets, TXA, desmopressin
• Can labs help you? While they may be abnormal, they are not really reliable in assessing amount of anticoagulation.

Timing of last dose is one of the most important factors in determining need for reversal. If greater than 24 hours, it is likely the medication has no further effect

Suggested / Further Readings:

• Articles / Posts
  • emDOCs – Reversing NOACs – Updates for Emergency Physicians
  • emDOCs – Reversal of Anticoagulation in a True Emergency
  • emDOCs – Management of Patients on Novel Oral Anticoagulants with Bleeding
  • R.E.B.E.L. EM – Dancing with the Devil: Taking Dabigatran to the OR
• Podcasts
  • emCrit Podcast 203 – New Reversals for New Anticoagulants with Nadia Awad
  • EM Cases Episode 88 – DOACs Part 1: Use and Misuse
  • EM Cases Episode 89 – DOACs Part 2: Bleeding and Reversal Agents