Synopsis
Prescribe factor Xa and direct thrombin inhibitors by indication and organ function, recognise clinically relevant residual effect and use specific reversal only when bleeding or urgent surgery justifies it.
- DOAC doses are indication specific: never transfer an atrial-fibrillation reduction rule to acute VTE or mistake an extended-prevention dose for initial treatment.
- Use Cockcroft–Gault creatinine clearance, not unadjusted laboratory eGFR, and repeat it during acute illness because drug accumulation can change within hours.
- Apixaban and rivaroxaban start acute VTE with intensified oral regimens; dabigatran and edoxaban require at least 5 days of therapeutic parenteral anticoagulation first.
Key red flags
Intracranial, spinal, pericardial, retroperitoneal or airway bleeding requires immediate multidisciplinary action even if haemoglobin and routine coagulation tests are initially reassuring.
Investigation priorities
Estimate residual effect, blood loss and clearance capacity.
Management branches
Dabigatran exposure accompanies life-threatening or uncontrolled bleeding or surgery that cannot safely wait.
- Stop dabigatran, resuscitate, control the source and record last dose, renal function, thrombin time and drug level if rapidly available.
- Give idarucizumab 5 g IV as two consecutive 2.5 g doses while definitive haemostasis proceeds.
Key medicines
IdarucizumabGive 5 g intravenously as two consecutive 2.5 g/50 mL infusions over 5–10 minutes each or bolus injections for dabigatran-associated life-threatening or uncontrolled bleeding or urgent surgery.
Andexanet alfa low doseGive 400 mg intravenously at about 30 mg/min, immediately followed by 4 mg/min for 120 minutes when the last apixaban or rivaroxaban dose and timing meet the low-dose table.