Reversal of oral anticoagulation

Abstract

Although the use of dabigatran and rivaroxaban are increasing, data on the reversal of their effects are limited. The lack of reliable monitoring methods and specific reversal agents renders treatment strategies empirical, and as a result, treatment consists mainly of supportive measures. Therefore, we performed a systematic search of the PubMed database to find studies and reviews pertaining to oral anticoagulation reversal strategies. This review discusses current anticoagulation reversal recommendations for the oral anticoagulants warfarin, dabigatran, and rivaroxaban for patients at a heightened risk of bleeding, actively bleeding, or those in need of preprocedural anticoagulation reversal. We highlight the literature that shaped these recommendations and provide directions for future research to address knowledge gaps. Although reliable recommendations are available for anticoagulation reversal in patients treated with warfarin, guidance on the reversal of dabigatran and rivaroxaban is varied and equivocal. Given the increasing use of the newer agents, focused research is needed to identify effective reversal strategies and develop and implement an accurate method (assay) to guide reversal of the newer agents. Determining patient-specific factors that influence the effectiveness of reversal treatments and comparing the effectiveness of various treatment strategies are pertinent areas for future anticoagulation reversal research.

Keywords: adverse drug reactions; anticoagulation; cardiology; patient safety; pharmacogenomics; pharmacology.

Figure 1. Inhibitory mechanisms of oral anticoagulants within the clotting cascade

Warfarin inhibits vitamin K epoxide reductase complex 1 (VKORC1); resulting in decreased activated clotting factors (II, VII, IX and X). Dabigatran inhibits thrombin (factor IIa) and rivaroxaban inhibits factor Xa. The end result of all three medications is an increased anticoagulant effect.