What are the recommended reversal strategies for patients on DOACs who present with major bleeding?

Recommended reversal strategies for patients on direct oral anticoagulants (DOACs) presenting with major bleeding:

• Rapidly reverse anticoagulation in patients with major bleeding who are on DOACs, especially in the context of major trauma or active bleeding.
• Hospital trusts should have protocols for rapid identification and reversal of anticoagulants, including DOACs.
• For reversal of vitamin K antagonists, prothrombin complex concentrate (PCC) is recommended immediately; however, for DOACs, specific reversal agents should be used as per MHRA safety advice and NICE technology appraisal guidance.
• Consult a haematologist immediately for advice on reversal of any anticoagulant agent other than vitamin K antagonists, including DOACs.
• For apixaban or rivaroxaban, andexanet alfa is recommended as a reversal agent according to NICE technology appraisal guidance.
• Do not reverse anticoagulation in patients who do not have active or suspected bleeding.

These strategies emphasize the importance of rapid assessment, use of specific reversal agents like andexanet alfa for factor Xa inhibitors, and specialist consultation for guidance on reversal of DOACs in major bleeding scenarios.

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